Community-Based Surveillance of Antimicrobial Use and ...

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2. Delhi, Indiaduring the time taken to collect the desired number of ABM‐containing prescriptions wasrecorded at each visit. These data allowed for the calculation of the percentage ofprescriptions with an ABM, and with a specific ABM. ABMs were categorized using ATCcodes, and the number of DDDs prescribed for each ABM per 100 patients visiting thefacility was calculated. In this case, the denominator was the number of patients who visitedthe pharmacy whether purchasing an ABM or not, during the time of data collection. Thedata collection process and data capture instruments were piloted before the actual surveycommenced.2.2.3 Data managementData on both AMR and ABM were captured using a locally developed data‐entryprogramme in FoxPro software and exported into Microsoft Excel 2003 for analysis. All datawere double entered to check for errors.2.3 FindingsAMR data were collected from November 2003 to December 2004 and ABM use data fromDecember 2003 to December 2004 at this site.2.3.1 AMR in E. coli2.3.1.1 AMR in commensals and pathogensAll samples were collected from women suspected of having UTI. Data on AMR wasavailable from 603 isolates collected over a period of 14 months, from November 2003 toDecember 2004. The overall AMR pattern is shown in Table 2.1 and Figure 2.1. Resistancerates among pathogens and commensals were high to all ABM tested. The rates were above70% for ampicillin and nalidixic acid. Over 50% of isolates were resistant to fluoroquinolonesand more than 20% resistant to third‐generation cephalosporins. Cross‐resistance toampicillin, nalidixic acid and cotrimoxazole was shown in 117 (51.1%) pathogens and 158(42.5%) commensals, and high levels of resistance to each of these ABMs was alsodemonstrated.Table 2.1: AMR in E. coli isolated during the period November 2003 to December 2004*PathogensCommensalsNo. testedNo.resistant % resistant No. testedNo.resistant% resistantAmikacin 222 35 15.8 245 29 11.8Ampicillin 227 192 84.6 376 267 71.0Cefotaxime 227 58 25.6 372 86 23.1Cephalexin 225 112 49.8 374 157 42.0Ciprofloxacin 215 123 57.2 249 126 50.6Cotrimoxazole 223 145 65.0 376 217 57.7Gentamicin 224 66 29.5 375 112 29.9Nalidixic acid 227 175 77.1 373 269 72.1Norfloxacin 225 132 58.7 375 168 44.8* The values for % resistance of commensals relate to all commensals. These values therefore lie in between thevalues shown in Figure 2.1 for commensal from normal isolation and those from modified isolation.19
Community-based surveillance of antimicrobial useand resistance in resource-constrained settingsFig.2.1: Annual percentage AMR rates in E.coli (November 2003 to December 2004)908070% resistance6050403020100Ampi Ceftx Cephal Cotrim Genta Nal NorflPathogen Commensal Commensal (modified isolation)2.3.1.2 Monthly trends in AMRA high degree of month‐to‐month variability was seen with some AMR rates. For example,initially there were very high rates of resistance to ampicillin and cephalexin, and these laterdeclined sharply. The numbers of isolates tested per month were small, especially in theearly part of the pilot study, and this may explain the degree of variability seen during thisperiod. After introducing the modification in method for isolating commensal E. coli, thenumbers of isolates obtained increased significantly. An average of 19 isolates per monthwas obtained during the initial 10 months, compared to an average of 72 isolates each monthduring the last two months of the pilot study. Lower rates of resistance rates to most ABMswere found in commensals obtained by modification compared to pathogens andcommensals obtained without modification, as seen in Figure 2.1. Urine can select outpathogenic E. coli and can be inhibitory to commensal E. coli. The modification introduced,where urine was diluted with culture broth, probably helped in isolating commensal bacteriapreferentially, while the commensals isolated from urine directly could possibly have been E.coli able to colonize the lower urinary tract. Quarterly AMR rates show less variability, andare depicted for both pathogens and commensals (Figure 2.2). While the results obtained arereported, it must be noted that the NCCLS/CLSI guidelines do not recommend testing E. colifor cephalexin susceptibility.20
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