This example describes work in Ghana to perform a baseline assessment of antimicrobial resistance. This assessment was used to inform the process to develop a National Policy on Antimicrobial Resistance in the country.
Antimicrobial resistance surveillance systems are often active and operational in resource-rich countries. Contrarily, resource-limited countries such as Ghana often do not have an active surveillance system, and there is limited or no data on resistance.
In 2011, Ghana formed an AMR working group and a national platform to drive forward a country-wide antimicrobial resistance agenda. The platform brought together actors from various fields such as regulatory authorities, pharmacists, microbiologists and research institutions. In order to have data to feed into the policy development process, it was decided to conduct a new baseline assessment of resistance, and a study team was appointed. Prior to this study, the latest available nation wide data in Ghana was generated in 2003. New national data was therefore urgently needed to assess the current situation and identify the needs for improved infrastructure and laboratory capacity.
Specific objectives of the study were to:
- Train/retrain selected laboratory technologists, and to harmonize protocols for carrying out susceptibility tests
- Collate and analyze surveillance data on antimicrobial resistance within six months after training
- Monitor and evaluate surveillance data, and to perform specific additional tests (eg. MICs)
- Create a repository of collected isolates for future studies
A three-day workshop was organized to harmonize susceptibility testing protocols, and to initiate the six-month study. The study team worked together with the AMR working group to select appropriate study laboratories and all ten regions of Ghana were represented. During the workshop, participants received a file with training materials and discussed the data-collection sheet. As part of the training lectures the theoretical basis and interpretation of susceptibility results were discussed. Participants performed susceptibility tests using their own methods and performed another test using standards. They then had the opportunity to compare the two results.
Selected study laboratories performed routine microbiological investigations on all clinical specimens received, using in-house standard operating procedures. Biweekly, biomedical scientists sent completed data sheets, together with bacterial isolates, to a central point using in-country courier systems. Further microbiological tests like Minimum Inhibitory Concentration (MIC) measurements, detection of Extended Spectrum Beta-Lactamases (ESBLs) and identification of Methicillin resistant Staphylococcus aureus (MRSA) were performed on randomly selected isolates at the central point. Data was stored and analyzed using WHONET.
During the 6-month study period, nine out of ten districts submitted a total of 1598 datasets. High prevalence of resistance (>70%) was observed in both gram-negative and gram-positive bacterial isolates against commonly used antibiotics such as ampicillin, tetracycline, chloramphenicol, and trimethoprim–sulfamethoxazole. High prevalence of resistance (>50%) was also observed against third-generation cephalosporins, and fluoroquinolones. This is worrisome as syndromic infections are often treated with these antibiotics.
Lab consumables were a major challenge for almost all the facilities. Originally it was anticipated that the local laboratories would be using their own equipment for culturing and testing. Almost all laboratories reported that they did not have some basic items like antibiotic discs, Mueller Hinton agar and swab sticks. Such consumables had to be given out for the facilities in critical need, however, this was not accounted for in the original budget.
Study organizers reported that they had good collaboration from some facilities in terms of data generation and reporting whilst others were dragging their feet despite follow up. More data was received from the southern part of Ghana compared to the northern part, which could consequently lead to bias while interpreting data for the surveillance system and policy. A reason for this might also be the lack of equipment in the southern part.
Considerations for setting up a laboratory-based surveillance system:
The study team from highlighted the following recommendations based on their experience:
- All district and regional hospitals should have functional microbiological laboratories, with capacity for culture and susceptibility testing. Good quality, regular and readily available laboratory materials for culture and susceptibility testing is needed.
- Clinical laboratories across the country need to be strengthened, especially, to do much more investigations on all infections, especially, blood-stream infections.
- As part of the reporting systems, laboratories within the country should be mandated to collate and share data on resistance.
- To ensure credible data, a well-coordinated internal and external quality assurance system is needed.
- A designated focal point/place is needed to coordinate antimicrobial resistance activities, for both local and global action, and national research laboratories can play an essential role.
- Antimicrobial resistance activities must be included in both national and facility budgets, and an effective monitoring and evaluation mechanism must be put in place.
- There is the need to study resistance at non-governmental health care facilities as well.
|Laboratory-based nationwide surveillance of antimicrobial resistance in Ghana||The study aims to generate baseline data on antimicrobial resistance and to assess the readiness of laboratory-based surveillance in Ghana.|
|Baseline Resistance Study (PDF)||A report on the training and laboratory surveillance of antimicrobial resistance in Ghana.|
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