Community-Based Surveillance of Antimicrobial Use and ...

Community-based surveillance of antimicrobial useand resistance in resource-constrained settingsthe laboratory within 3‐4 h after collection. During this transit time, they were stored undercool conditions (initially in a refrigerator and then in cold bags while in transit).In patients with suspected UTI, E. coli isolated in pure growth and in counts above 1000colony‐forming units/ml was counted as an infecting strain (pathogen). All isolates of E. colifrom deliberately contaminated urine were counted as commensals. Approximately 80isolates (40 from each centre) were collected every month.3.2.1.2 Identification of bacteria and susceptibility testingUrine samples were plated on both blood agar and MacConkey agar in 0.01ml amounts. Theisolates were identified as E. coli on the basis of colony morphology, negative oxidase test,reaction on triple sugar iron (TSI) agar, mannitol fermentation, ability to produce indolefrom peptone water, and inability to utilize citrate or split urea.Susceptibility testing was performed on Mueller Hinton agar (Hi Media, India) followingNCCLS/CLSI 2002 criteria (2002). Discs for testing were either obtained from Hi Media(India) or prepared in the laboratory. Reference strains were tested, as recommended byNCCLS/CLSI, every time susceptibility testing was performed. Readings for the test strainswere taken only if the results for each antibiotic with the reference strains were acceptable.The site also participates in the quality assessment programme for microbiology laboratoriesunder the auspices of the Indian Association of Medical Microbiologists (IAMM), which isoperated by CMC Vellore, India.Data on AMR were maintained in dedicated laboratory registers and also entered into studyquestionnaires.3.2.2 ABM use3.2.2.1 Facility selectionABM use data were obtained from three types of facilities: 1) hospitals or PHC clinics(including not‐for‐profit and for‐profit hospitals in the urban area and public sector PHCclinics and a not‐for‐profit hospital in the rural area); 2) private sector pharmacies; and 3)private sector general medical practitioners’ practices. A sample of five urban and five ruralfacilities from each type (30 in total) was made, and ABM use data were obtained from thesefacilities each month. The CMC Hospital and the RUHSA hospital (both not‐for‐profitmission hospitals) were included in the urban and rural samples, respectively. However,patient exit interviews were not conducted at CMC Hospital. Private sector pharmacies,general practitioners and hospitals were not selected randomly but on their willingness tocooperate. All the government PHC facilities in the rural area were included in the sample.All facilities were situated in the same locations as the antenatal patients, from whomsamples for AMR purposes were obtained, were living.ABM use data were obtained from bulk sales/purchase records and also from exit interviewsconducted by pharmacists from facilities in the same area.28