Community-Based Surveillance of Antimicrobial Use and ...

Community-based surveillance of antimicrobial useand resistance in resource-constrained settings8.3 Lessons learnt concerning methodologyCommunity‐based surveillance projects on this scale have rarely been conducted in resourceconstrainedsettings, especially in Africa and Asia. The methodological challenges faced ineach site, which impacted on data quality, are important as they provide useful lessons.8.3.1 AMRThe projects were initiated to develop and pilot‐test methods to understand time trends ingiven areas, and in consequence different methods of data collection were used at differentsites. If the same methodology is followed throughout in an area, the data could be used forcomparing time trends in that area and also for evaluating the impact of interventionscarried out in that area. However, in order to compare data from different sites (which wasnot an objective of this project), better standardization of different aspects of data collectionwould be required.8.3.1.1 Collection of indicator bacteria• E. coli was used to document AMR at four sites while S. pneumoniae and H. influenzaewere used at one site. Sites using E. coli were able to generate higher numbers of isolatesto document AMR. For surveillance of AMR on a large scale and among populations inthe community, E. coli has been used successfully in other studies and is probably themost popular indicator bacterium for this purpose 48, 49. S. pneumoniae and H. influenzaehave been used to document AMR by other workers 50 . Like E. coli, these can be a part ofnormal flora but have the potential to cause disease. There are other bacteria in therespiratory tract that can be reservoirs of resistance and practical for documenting AMR.• Using commensal bacteria with a potential to cause infections is a good method togenerate surveillance data on AMR. Non‐fastidious organisms like E. coli are probablymore suitable for this purpose than ‘difficult to handle’ organisms like S. pneumoniae andH. influenzae, especially in areas where the performance of bacteriological procedures isstill in the developmental stage. It may be worth considering using more than one type ofindicator organism to understand more clearly the AMR issues in a given area.• Various methods were pilot‐tested for collecting isolates for surveillance of AMR. E. coliisolated from urine samples of individuals with suspected or proven UTI had a differentsusceptibility pattern from those from individuals with no evidence of infection.Therefore, it is necessary to define and standardize the sources if comparison betweensites is an objective. It may also be necessary to include commensals in a planned mannerin order to obtain sufficient numbers of isolates for time trend analyses.• Using urine as source of E. coli had several advantages. Compliance for this type ofsample collection was good. In two sites, both pathogens and commensals were obtainedseparately for testing by applying a few additional simple steps to differentiateuninfected individuals from infected ones. This was done by asking for symptoms andtesting by dipsticks for leucocytes and nitrate reductase. This method had the additionaladvantage of providing treatment for those participating subjects who were infected.However, training and supervision is required for all staff collecting samples. Thenumbers of isolates obtained by this approach were smaller than those obtained usingfaecal samples for E. coli. With faecal E. coli, only commensal flora could be tested, andthe patients had to make a return visit to the clinics to submit the samples. This has the88