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