Methodological challenges for AMR surveillance

programmes

Gous AGS, Pochee ESchool of Pharmacy

Medical University of Southern Africa

Introduction Background on the AMR surveillance

programme at Brits/Madibeng District Challenges in setting up a District-

Based AMR Surveillance Programme What are the challenging

methodological issues in AMR surveillance in communities?

Which methods questions should be included in a future research agenda in AMR surveillance in communities?

Background Aim

To set up a district-based surveillance programme of antimicrobial use (for all clinical conditions)

and resistance of Escherichia coli in the urine of patients with suspected uncomplicated urinary tract infection

Requirements 100 E. coli isolates per month 30 antimicrobial-containing prescriptions

per month per collection site

Background

Case definition

Inclusion criteria Urine specimens will be obtained from

women with the following signs and symptoms: Dysuria Urgency and frequency of micturition Suprapubic pain, feeling of fullness or a

sensation of pressure

BackgroundExclusion criteria All male patients Patients younger than 13 years Patients with recurrent UTIs

Recurrent UTIs are defined as proven UTIs in the past six months

Patients who were hospitalised in the past month

Patients on treatment for bacterial infections in the past month

Patients with abnormal vaginal discharge or genital ulceration

Background

Participating facilitiesin the Brits/Madibeng District, North West Province, South Africa (see map)

Outpatient and emergency departments of Brits Hospital, a public district hospital

Six primary health care clinics Three clinics under the North West Department of

Health Two clinics under the Brits/Madibeng City Council One Non-Governmental Organisation (NGO) clinic

Five private community pharmacies Five private medical practitioners

Map of the study area

South Africa

Challenges during set-up and implementation

1. Existing surveillance programmes are confined to academic and tertiary health care institutions

2. Finding community partners

3. Commitment of different stakeholders varies

Challenges during set-up and implementation (continued)

4. The logistics of data collection were complicated by:

The distance between the different sites Remoteness of some sites Lack of regular transport

5. Approval and start of the programme was delayed by:

Health management changes Demarcation of districts New appointments in management positions

Sensitivity towards research 6. Establishment and ongoing restructuring

of the National Laboratory Services

Challenges during set-up and implementation (continued)

7. Detailed patient information and consent forms had to be designed and translated into several languages

8. It was a challenge to plan the study without knowing what data sets may be needed to ensure appropriate data collection to identify shortcomings in antimicrobial use as well as consumption over time at all levels of the health system

Challenges during set-up and implementation (continued)

9. Training sessions had to be postponed or repeated due to

Location of the different sites Lack of transport Staff workload: prevents the release of

staff to attend the sessions Staff turnover

Challenging methodological issues Sampling of urine specimens Identifying and enrolling suitable patients

Inclusion criteria Exclusion criteria Antenatal patients

Obtaining consent Workload Dedicated people

Obtaining specimens Patient education Antenatal patients

Storage and transport of specimens Processing The use of culture and sensitivity results to guide therapy

Challenging methodological issues (continued)

Antimicrobial use Acute vs chronic prescriptions

TB PC prophylaxis

Access to patient information Patients retain their files Diagnosis not provided on private prescriptions

Prescription journals Require staff with knowledge on antimicrobial use Each primary health care worker has his/her own

prescription journal Doctors do not record their prescriptions in a prescription

journal, only on the patient’s file

Which methods questions should be included in future research? The need for consent Inclusion criteria Modifying standard procedures of processing

specimens Acute vs chronic prescriptions Data sets

Intervention on usage of drugs that will not impact on UTI treatment

Collecting more data than what is required for surveillance

What to do if there is a need to intervene during initial phase of the surveillance programme