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WHO local pilot projects to
contain AMR
ICIUM 2004
K.A.Holloway and T.L.Sorensen
Essential Drugs and Medicines Policy
WHO Geneva
Why local pilot projects?
• WHO global strategy published 2001 recommends 67
interventions but no country is implementing them all
and few countries could do so
• Very little evidence to use in prioritising interventions
• Very little epidemiological AMR or use surveillance
• Governments will need evidence before they act
• Local surveillance may provide the evidence for local
communities to act and later for government to act
• Urgent need to develop a methodology suitable for
local routine use
Objectives
• develop, implement & evaluate interventions to
contain AMR using surveillance data
• develop a new methodology for the integrated
surveillance of antimicrobial use and resistance
- that can be used in many different countries
• to build local capacity in developing a
multidisciplinary approach to the containment
of antimicrobial resistance
Method for integrated surveillance (1)
• Resistance to antimicrobials of 1-2 selected
organisms in patients with pre-defined clinical
condition in hospital OPD & PHC facilities on
presentation before treatment
– Strep.pnuemoniae in throat swabs in ARI cases, E.Coli
in MSUs in UTI cases, Shigella in faeces in dysentery
cases, gonococcus in urethral swabs
– Resistance rate in terms of cases, not isolates
– Data collected monthly
Method for integrated surveillance (2)
• Antimicrobial use at all health care levels in the same
locations as the specimens for AMR testing are taken
– Hospital OPD patients with pre-defined clinical condition
– Antimicrobial use for all clinical conditions in shops, PHC
facilities (public and private) and hospital OPD
– Data collected monthly
• Analysis of baseline time series data
– What are the trends in resistance and use?
– Are resistance patterns in community-acquired infections
similar in hospital & PHC outpatients?
– What proportion of patients have resistant infections?
– What is the impact of a local intervention on local
antimicrobial use and resistance?
Choosing sites
• Multi-disciplinary capacity within single institution
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–
–
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pharmacology and expertise in drug use studies
microbiology and infectious diseases
public health and primary health care
social sciences for behaviour interventions
• Contacts in-country for coordination & supervision
– pharmaceutical support programmes in India and S.Africa
– communication problems common without local “contact”
• Site visit following letter of intent from institution
–
–
–
–
–
expressions of interest from Vietnam, Sri Lanka, Iran, Kenya
Lab. inspection - only S.African labs had true external QA
meeting with all concerned specialists
proposal writing and revision - usually takes > 1year
drop-out rate after visit of 50%
Current Projects
BYL Nair Medical College, Mumbai, India - started 09/02
• Commensal E.Coli resistance in patients’ faeces and antimicrobial use in
shops, dispensaries, private practitioners and hospital OPD
CMC Vellore, Tamil Nadu, India – started 08/03
• Commensal & pathogenic E.Coli resistance in urine of pregnant women
and antimicrobial use in rural and urban areas
Gangaram private hospital, Delhi, India – started 11/03
• Pathogenic E.Coli resistance in urine of women with suspected
uncomplicated UTI and antimicrobial use in hosp OPD and local shops
Durban Westville, S.Africa - started 07/02
• Commensal and pathogenic S.Pneumoniae and H.Influenzae in sputum
patients with a productive cough & public/private antimicrobial PHC use
MEDUNSA, S.Africa - started 07/03
• Pathogenic E.Coli resistance in urine of women with suspected
uncomplicated UTI and public/private antimicrobial PHC use
80
70
60
50
40
30
20
10
0
10
8
6
4
2
Drug use
Resistance
Se
p
Ju
l
A
ug
N
ov
D
ec
Ja
n
Fe
b
M
ar
A
pr
M
ay
Ju
n
ct
0
O
% patients receiving
cotrimoxazole
12
% isolates reistant to
cotromixazole
Looking at trends in cotrimoxazole resistance
and use in Mumbai, India, 2002
Establishing differences in E.Coli resistance
levels in rural & urban areas in Vellore, 2002
45
Rural cotri
resistance
Urban cotri
resistance
Rural amoxy
resistance
Urban amoxy
resistance
Rural cipro
resistance
Urban cipro
resistance
40
35
30
25
20
15
10
5
0
Aug
Sept
Oct
Nov
Dec
25%
20%
15%
10%
5%
0%
100%
80%
60%
40%
20%
0%
% resistant
sputum
isolates
% patients
treated
with cotri
Monitoring community cotrimoxazole resistance
and use in Durban, S.Africa, 2002-3
10 11 12 1 2 3 4 5 6 7
PHC clinics
Pharmacies
H.influenzae resist.
S.pneumoniae resist.
Private Practitioners
Problems encountered
• Poor coordination sometimes between team conducting
microbiology and team undertaking drug use surveillance
• Insufficient sample size to adequately detect monthly
trends in resistance
– number of patients
– number of isolates
• Patients giving specimens have already taken antibiotics
• Specimens not always taken adequately so resulting in
non-growth
• Access to private sector difficult
• Difficulty to analyse use in association with resistance
Conclusions
• Five projects started and resulting in:
– Multidisciplinary teams
– Experience in surveillance
– Development of a basic local surveillance tool to use in
evaluating the impact of local interventions
• Effort to use routine methodologies so as to
facilitate later sustainability
• Need multidisciplinary expertise in one site
• Advisory committee in India coordinated by
DSPRUD/WHO pharmaceutical support
Key lessons, policy implications and
future research
Key lessons
• It is feasible and useful to undertake surveillance of resistance and use in
communities in developing countries
• Such surveillance has provided local data and stimulated the formation of
locally-based multi-disciplinary teams better able to address AMR
Policy implications
• Local community surveillance to provide local data and build
understanding may better aid the development and implementation of the
multi-sectoral strategies needed to contain AMR, than national meetings
Future research
• Further community-based surveillance of resistance and use in order to
evaluate the impact of interventions and identify the most effective ones