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 is not yet available, data can still be collected on a smaller scale. Often, even small-scale studies can be useful to inform decisions. 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 makes data comparison difficult.
From prevalence studies to routine surveillance
Sweden was one of the first countries to implement long-term monitoring of antibiotic resistance. STRAMA, the Swedish strategic program against antibiotic resistance started by conducting prevalence studies and today, all counties are involved in an extensive surveillance program, involving nearly all microbiological laboratories in collecting data in a standardized and organized fashion. The laboratories report data daily into a database and in return they receive educational training, feedback and discussion forums. Data is also fed into additional surveillance systems such as EARS-Net, the European surveillance network. A report is generated daily on early warnings of resistance phenotypes that have been pre-defined as “extraordinary”. This real-time surveillance system can be used for internal control of data and is also used by the laboratories as an alert if a outbreak occurs. 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.
Integrated surveillance between sectors
It is recommended in the the National Action Plans 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 (OIE). 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 Surveillance System (GLASS)
To aid implementation of routine surveillance on a national and global level, WHO has initiated the Global Antimicrobial Resistance 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 is being developed 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.
The following text highlights some of the recommendations in the GLASS manual for early implementation.
For participation in GLASS, it is required to establish a national coordinating center, a national reference laboratory and at least one surveillance site. Data on progress of implementation of a national surveillance system will be monitored and countries that are not yet able to submit resistance data can still participate.
Steps to set up a national surveillance system:
- Establish a national surveillance coordinating body with a focal point and a data management structure.
- Define the surveillance objectives to:
- Assist planning and monitoring of the national antimicrobial resistance strategy
- Inform global efforts to control antimicrobial resistance
- Define a strategy for gradual implementation of the national surveillance system and participation in GLASS.
- Establish at least one national reference laboratory that participates in an external quality assurance scheme.
- Identify antimicrobial resistance surveillance sites, that have access to epidemiological support and a microbiology laboratory, and promote diagnostic stewardship.
- Develop or adapt national protocols for:
1. data collection
2. laboratory protocols
3. diagnostic stewardship
4. data flow
- Disseminate protocols and tools, and train staff in their use.
- Start collecting data on progress or status of implementation and on antimicrobial resistance.
- Report information on the antimicrobial resistance situation to inform the national strategy, and report aggregated data to GLASS to inform global strategies.
- Ensure that monitoring and evaluation include pilot-testing of any new surveillance approach, a review of steps, and adjustment of processes as necessary.
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 enrollment 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 to resistance surveillance in animals so they can eventually be integrated together.
Implementing a surveillance program in Nepal:
In 1998, the Nepalese Ministry of Health and the United States Agency for International Development launched an infectious disease program that was aimed at developing awareness among physicians about resistance and establishing a surveillance program. The program started with a planning workshop to build the program team, discuss strategies and establish a forum for stakeholders and was initially implemented by the International Centre for Diarrheal Disease Research, Bangladesh, in collaboration with the Rational Pharmaceutical Management Project, US.
The National Public Health Laboratory was designated national coordinating laboratory and the Epidemiology and Disease Control Division was designated as the national focal point. National capacity building initiatives through training and workshops were conducted to develop a pool of trainers. The training program also contributed to national laboratory capacity building, standardization and use of protocols for selected pathogens. The program also helped the National Public Health Laboratory to build capacity for storage of isolates, creating a sense of ownership of the program and motivating the Ministry of Health, Nepal to increase the resources for laboratories. In summary, the program seems to have laid a foundation for conducting laboratory-based surveillance in Nepal.
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 will regularly report to WHO on progress in implementing national surveillance as well as resistance levels and unusual findings. This data will provide input to a bi-annual report on global resistance surveillance
Priority pathogens, specimen types to be collected and a selection of antibiotics against which resistance can be monitored are outlined in the GLASS manual. 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.
|GLASS – Global antimicrobial Resistance Surveillance System – Manual for early implementation||Manual that details the approach for early implementation of the GLASS surveillance system and is intended for national public health professionals and authorities in charge of surveillance of antibacterial resistance in humans. Also available in Chinese, French, Russian, and Spanish. See also GLASS resource Centre for guidelines and tools for enrolment, data management and capacity building.|
|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.|
|AMR Surveillance in low- and middle-income settings: A roadmap for participation in the Global Antimicrobial Surveillance System (GLASS)||Journal article with information for implementation of surveillance in low resource settings. The guideline is aligned with the Global Antimicrobial Resistance Surveillance System (GLASS) procedures but offers higher flexibility across different systems.|
|Central Asian and Eastern European Surveillance on Antimicrobial Resistance (CAESAR)||Information portal – CAESAR project webpage. The CAESAR project is coordinated by WHO EURO and aims to set up national antimicrobial resistance surveillance systems in European countries that are not part of EARS-Net. See also accompanying manual with protocols and instructions for routine data collection and antimicrobial case definitions.|
|European Antimicrobial Resistance Surveillance Network (EARS-Net)||Information portal and database. EARS-Net is a network of national surveillance systems across Europe that provide European reference data on antibiotic resistance for public health purposes. The network is coordinated and funded by the European Centre for Disease Prevention and Control. On this page it is possible to access surveillance reports and the protocol for reporting into EARS-Net.|
|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.|
|Epi Info||A software tool for collecting, analyzing and managing epidemiological data, developed by the CDC (US). Can be used for assessment of disease outbreaks or the development of small or mid-size surveillance systems. Epi Info is free of charge and can be implemented in settings with limited network connectivity making it a suitable option for resource-constrained settings. The software is translated into multiple languages.|
|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. Read more about the WHO Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR) here|
|OIE 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.|
|OIE Aquatic Animal Health Code||Guidelines. OIE guide to development and harmonisation of national antimicrobial resistance surveillance and monitoring programmes for aquatic animals. Chapter 6.3: Monitoring of the quantities and usage patterns of antimicrobial agents used in aquatic animals. Chapter 6.4, Development and Harmonisation of National Antimicrobial Resistance Surveillance and Monitoring Programmes for Aquatic Animals.|
|Challenges of animal health information systems and surveillance for animal diseases and zoonoses||Report containing proceedings of a workshop organized by FAO in 2010. The workshop concluded that measures for disease surveillance need to be taken to reduce animal health-related risks and to avoid negative effects of disease outbreaks on food production and livelihoods.|
|Strengthening the Role of Laboratories in Tracking Antimicrobial Drug Resistance in East Africa||Report reviewing costs and benefits of AMR surveillance, and whether the East Africa Public Health Laboratory Networking Project laboratories are ready to participate in national AMR surveillance.|
|Combating antibiotic Resistance: A Policy Roadmap to Reduce Use of Medically Important Antibiotics in Livestock||Report containing a policy roadmap with 11 core policy recommendations aimed at a broad set of stakeholders: policymakers, food companies, institutional food purchasers (i.e. hospitals, schools and universities), and medical groups. The recommendations are divided into three key areas: 1) decreasing livestock use of medically important antibiotics; 2) monitoring livestock antibiotic use, and 3) enhancing surveillance and data integration to inform antibiotic resistance policy.|