Monitoring AMR: Step zero in the fight against AMR
Announcements :
C-CAMP has organized two new programs in the field of AMR.
a) The Inaugural SBI Foundation & C-CAMP’s AMR Challenge &
Read about the challenge:https://www.amrccamp.in/iaih/coe
Application form: https://docs.google.com/forms/d/e/1FAIpQLSct8ilb-lKD319GYB32SQ6twEqyEkvvw9644IHn--5UoiHBBA/viewform
b) School for AMR innovators working on in-vitro diagnostics with CARB-X
Read about the Innovator’s School:
Application form:https://docs.google.com/forms/d/e/1FAIpQLSfWD91ZEeFknDkT4PDXvY8lV8riiYsHjCGQopq0P3QBUsY7zg/viewform
Introduction
Over the past two decades, the risks of antimicrobial resistance (AMR) have been extensively studied. It is estimated that by the year 2050 the yearly loss in lives would be 10 million and a loss of 2–3.5% of the global GDP costing the world up to 100 trillion USD [1,2]. While research and innovation in AMR has shown promising prospects, as of now, a definitive solution for AMR is far from reach [3]. Antibiotics are an integral part of modern medicine; thus, stopping their use is not a viable solution to fight AMR. AMR is widely studied at the clinical settings but its understanding from the environmental standpoint remains limited [3].
The use of antimicrobials in agriculture and animal husbandry increases the selection pressure on microbes, increasing the chances of generation of resistant microbes. These resistant microbes can be pathogenic to humans directly. Or they can mutations conferring resistance to human pathogens through horizontal gene transfer (HGT) [1,2]. Therefore, considering the health and economic costs of AMR, it becomes imperative to constantly monitor and survey not only the clinical prevalence of AMR but also the environment for new emerging AMR strains and genes.
Global efforts for local monitoring
To tackle this problem, World Health Organization (WHO) under the Global Action Plan for AMR (GAP-AMR) developed and formulated the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 [5]. GLASS is the first global effort to standardize AMR surveillance. GLASS aims at providing standardized approaches to enhance AMR surveillance by designing optimized and standardized protocols for sample collection and analysis. One of the major objectives of GLASS was to develop an easy protocol to identify and quantify the frequency and occurrence of resistant bacterial species. This helps in uniformity of interpretation and modeling of disease patterns based on various parameters such as clinical, socio-economic, geographical, etcetera [5]. As of 2023, 130 countries are registered to ensure GLASS at the country level, this includes India as well [6].
Monitoring AMR in the environment is a humungous task. Unlike a clinical setting where patient history can reveal a lot of information, identifying the source of an AMR pathogen in an environmental context becomes difficult due to its complexity. To achieve this, the “TRIcycle Project”, a One health-based approach, was designed by the Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR) and the WHO Surveillance Prevention and Control of AMR. The TRIcycle Project has identified extended-spectrum beta-lactamase producing Escherichia coli (ESBL-Ec) as an AMR indicator. ESBL-Ec is identified as the universal indicator due to its widespread existence. India was one amongst the first countries to employ the TRIcycle Project [7].
In line with the One Health approach of integrating healthcare system with the environment [8], the TRIcycle project recorded, monitored, and analyzed the occurrence of ESBL-Ec simultaneously in the areas of human health, food chain, and environment to achieve improved global surveillance against AMR [9]. The major workflow from the project has been highlighted below.
1. Surveillance in humans: Two sets of populations are chosen for this based on the criteria that most E. coli is an entero-bacterial pathogen and is prevalent in blood culture. Data is collected from patients having bloodstream infections and healthy pregnant women fecal matter is tested for analyzing community level infections [9].
2. Surveillance in food chain: Poultry was chosen as the species for surveillance due to universal frequent consumption, availability and rearing. The chicken feces are routinely collected and sampled for ESBL-Ec [9].
3. Surveillance in the environment: Most of the environmental infections are known to be water borne. Samples are collected from hotspots which includes the areas of rivers where wastewater is dispersed, upstream and downstream areas of the river [9].
All the protocols including sample collection, storage, statistical analysis, distribution, and analysis are explained in the WHO workbook [9].
This AMR surveillance program ultimately aims at a better-quality healthcare system. Along with Antimicrobial Stewardship (AMS) [10] WHO is also focusing to improve healthcare system, ensure supply of quality medical supplies, and improve healthcare across the world.
TRIuMPH of the TRIcycle project
Building on the TRIcycle project, the TRIuMPH project was conceived to extend the protocol to Carbapenemase-producing Enterobacteriaceae (CPE), characterize CPE strains using whole genome sequencing, and developing new low-cost protocols tailored for low- and middle-income countries (LMICs) [11].
India’s Efforts
India has adopted the policies of WHO and furthermore has formulated its own surveillance wing called the Antimicrobial Resistance Surveillance and Research Network (AMRSN) headed by the Indian Council for Medical Research (ICMR). The main aim of AMRSN is to generate a database of drug resistant infections and understand the patterns. The AMRSN has genotypically characterized a wide range of pathogens from Enterobacterales to fungal pathogens and has been tracking their susceptibility to various antimicrobials including colistin. Towards this, ICMR has formulated Standard Operating Procedures (SOP) in a species-specific manner for diagnosis and documentation [12].
WHO, with its One Health oriented programs TRIcycle and TRIuMPH, has established a universal and general protocol for the environmental surveillance of AMR. India, with AMRSN has developed a robust protocol for the clinical surveillance of AMR but a similar effort in environmental survey is yet to be achieved.
Disclaimer: The blog is a compilation of information on a given topic that is drawn from credible sources; however, this does not claim to be an exhaustive document on the subject. It is not intended to be prescriptive, nor does it represent the opinion of C-CAMP or its partners. The blog is intended to encourage discussion on an important topic that may be of interest to the larger community and stakeholders in associated domains
References
1. Larsson, D.G.J., Flach, CF. Antibiotic resistance in the environment. Nat Rev Microbiol 20, 257–269 (2022). https://doi.org/10.1038/s41579-021-00649-x
3. Hart Alwyn, Warren Jonathan, Wilkinson Helen, Schmidt Wiebke. Environmental surveillance of antimicrobial resistance (AMR), perspectives from a national environmental regulator in 2023. Euro Surveill. 2023;28(11):pii=2200367. https://doi.org/10.2807/1560-7917.ES.2023.28.11.2200367
4. https://www.who.int/publications/i/item/9789241509763
5. https://www.who.int/initiatives/glass
6. https://www.who.int/initiatives/glass/country-participation
7. https://www.hhs.gov/sites/default/files/day2-04-keelara.pdf
8. https://www.who.int/news-room/questions-and-answers/item/one-health
11. https://www.rivm.nl/en/global-health-security/antimicrobial-resistance/triumph
12. Annual Report 2022: AMR surveillance Network, Indian Council of Medical Research
