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Policy  –  Implement the plan

Surveillance of antibiotic resistance

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. 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 make 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 an 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 (WOAH, founded as 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 Resistance and Use Surveillance System (GLASS)

To aid implementation of routine surveillance on a national and global level, WHO has 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 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 is 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 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.

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 US Rational Pharmaceutical Management Project.

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 Nepalese Ministry of Health 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 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.

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).
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.
Antimicrobial Resistance in Low and Middle-Income Countries: An Analysis of Surveillance Networks Report describing the role of supranational networks in AMR surveillance in LMICs and their impacts and challenges. It also reflects on the implications of the analysis for the Global Antimicrobial Resistance Surveillance System (GLASS).
Stepwise approach for implementation of antimicrobial resistance surveillance in Africa Journal article. Provides practical guidance for laboratory-based surveillance of antimicrobial resistance in African countries. Presents a framework for stepwise implementation.
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.
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.
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.
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.
East Africa Public Health Laboratory Networking Project – 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.