Role of registries in tackling the problem of AMR.
A team led by Shraddha Karve of Ashoka University, India, won the Wellcome Trust award (1) to understand how the weather might impact antimicrobial resistance patterns. Such exploratory ideas in AMR surveillance would not have been possible without the availability of publicly available data.
These platforms, which fall under the gamut of clinical registries, are a treasure trove to map AMR in a rapidly changing world. The standardized foundation for this was laid by the WHO in 2015 with the launch of the Global Antimicrobial Resistance and Use Surveillance System (GLASS).
The requirement for efficient diagnostics is underscored in low and middle-income countries, as exemplified by the success of low-cost diagnostics for malaria, HIV, and SARS-CoV-2 (2). Since the diagnosis of antibiotic susceptibility is time-exhaustive and expensive, the current use of broad-spectrum antibiotics is unhindered. An input of extensive information on national and global resistance data could help primary care physicians make informed decisions potentially discouraging antibiotic use.
AMR Registries
There are a number of global and national AMR registries which have contributed to more than 200 research papers with contextually analysed data. A few are listed below:
The scope of GLASS as per WHO, “GLASS provides a standardized approach to the collection, analysis, interpretation and sharing of data by countries and seeks to actively support capacity building and monitor the status of existing and new national surveillance systems. Furthermore, GLASS promotes a shift from surveillance approaches based solely on laboratory data to a system that includes epidemiological, clinical, and population-level data. GLASS has been conceived to progressively incorporate data from surveillance of AMR in humans, such as monitoring of resistance and the use of antimicrobial medicines, including AMR in the food chain and in the environment.”
AMR Register, developed by Vivli with a grant awarded by the Wellcome Trust, shares data collected by pharmaceutical companies to track pathogen resistance and susceptibility. The AMR register sources data from surveillance programs of pharmaceutical companies like Pfizer (ATLAS) and Merck (SMART).
3. Antibiotic resistance information exchanges (ARIE)
In the United States of America, ARIE or Multidrug-Resistant Organism (MDRO) alerts track patients infected with specific MDROs and alert healthcare providers when these patients are admitted to another facility.
Developed by the British Society for Antimicrobial Chemotherapy in collaboration with the University of Aberdeen Epidemiology Team, the registry aims to, “provide prescribers and organisations the opportunity to capture real world usage of antimicrobial agents and identify where the real clinical unmet need lies. This will provide an invaluable resource for future research studies and also enable the sharing of best practice.”
An exhaustive list of registries is hosted at the Joint Programming Initiative on Antimicrobial Resistance.
One Health approach to AMR surveillance
To widen the surveillance to include the coverage of drug-resistant zoonotic diseases (3), institutions worldwide subscribe to Open Health (OH) guidelines. OH guidelines promote “a multi-disciplinary response to tackle AMR that includes human health, animal health, food production, and the environment” (4). The OH Quadripartite initiative works with the Food and Agriculture Organization of the United Nations (FAO), the United Nations Environment Programme (UNEP), and the World Organisation for Animal Health (WOAH).
AMR registries in Low and Middle-Income Countries (LMIC)
An analysis in Chile, concluded that there is increased awareness of AMR in human medicine than in veterinary medicine, agriculture, or food production.
Experts suggest genomic approaches to map interspecies drug resistance (5). Several countries restricted to Europe and North America are opting to approach surveillance through whole-genome sequencing. However, in spite of its many advantages of high specificity, it is marred by the requirement of infrastructure and trained personnel, particularly arduous in LMICs (6). This methodology also requires vast and varied specimen representation, which is a challenge to the fledgling AMR registries of LMICs.
The efforts and the ingenuity of these initiatives are appreciable. For example, using the One-Health approach, India has collected 0.4 million patient records as of 2022 to its one-stop repository i-AMRSS. The Indian National Centre for Disease Control hosts a National AMR surveillance network, which includes two national reference labs and 40 medical colleges. This data is also submitted to GLASS annually (7). Additionally, in 2023, India launched drug-resistant surveillance efforts in the field of leprosy to detect resistance to standard drugs, anti-leprosy rifampicin, dapsone, and ofloxacin (8).
Although these initiatives are beneficial, it is necessary for low and middle-income countries to have an integrative approach, including regulating the usage of antibiotics in food production. An analysis in Chile, for example, concluded that there is increased awareness of AMR in human medicine than in veterinary medicine, agriculture, or food production (9).
On the surveillance data use and contribution by LMIC (10), Rebecca Li, executive director at Vivli states, “ We have 81 countries that are represented in the data sets, including 40 LMICs. It would be interesting to see researchers coming from these countries and accessing the data, and we’re very hopeful for that.”
In 2022, scientists at the University of West England Bristol and Federal University Oye-Ekiti Nigeria indicated lacunae in implementing GLASS in Africa. Significant findings are that the implementation in 23 of the 47 countries lacks external quality assessment measures (11). Recent reviews and updates to OH also suggest conducting regular evaluations of a surveillance system’s processes and performance (12). These global inputs and synchronized expertise led to the establishment of CoEvalAMR in 2019. The group discusses evaluation frameworks for integrated surveillance as per the OH approach. It is also a practical guideline for setting up a use and resistance methodology and evaluation tools.
The future
It is encouraging to observe that many nations are evolving from voluntary submission of resistance data to a compulsory requirement for hospitals being covered by government national insurance programs (13).
In addition to political will and national action policies, innovations in data management are also necessary for the success of surveillance programs, especially in LMICs. As scientists from Nepal observed, considerable data cleaning and standardization efforts are required (14).
Citizen opinion on data security is overall supportive if a few conditions are met: personal data should be de-identified, data use should be regulated, and analyses should guide trusted health care decision-makers (15).
REFERENCES:
2. Chen, Z., Azman, A. S., Chen, X., Zou, J., Tian, Y., Sun, R., Xu, X., Wu, Y., Lu, W., Ge, S., Zhao, Z., Yang, J., Leung, D. T., Domman, D. B., & Yu, H. (2022). Global landscape of SARS-CoV-2 genomic surveillance and data sharing. Nature genetics, 54(4), 499–507. https://doi.org/10.1038/s41588-022-01033-y
3.Dafale, N. A., Srivastava, S., & Purohit, H. J. (2020). Zoonosis: An Emerging Link to Antibiotic Resistance Under “One Health Approach”. Indian journal of microbiology, 60(2), 139–152. https://doi.org/10.1007/s12088-020-00860-z
4. https://www.who.int/news-room/questions-and-answers/item/one-health
5. Ikhimiukor, O. O., Odih, E. E., Donado-Godoy, P., & Okeke, I. N. (2022). A bottom-up view of antimicrobial resistance transmission in developing countries. Nature microbiology, 7(6), 757–765. https://doi.org/10.1038/s41564-022-01124-w
6. Calero-Cáceres, W., Ortuño-Gutiérrez, N., Sunyoto, T., Gomes-Dias, C. A., Bastidas-Caldes, C., Ramírez, M. S., & Harries, A. D. (2023). Whole-genome sequencing for surveillance of antimicrobial resistance in Ecuador: present and future implications. Revista panamericana de salud publica = Pan American journal of public health, 47, e8. https://doi.org/10.26633/RPSP.2023.8
7. National Program on AMR Containment — https://ncdc.gov.in/index1.php?lang=1&level=2&sublinkid=384&lid=344
9. Cornejo, J., Asenjo, G., Zavala, S., Venegas, L., Galarce, N., Hormazábal, J. C., Vergara-E, C., & Lapierre, L. (2022). Advances in Integrated Antimicrobial Resistance Surveillance and Control Strategies in Asia-Pacific Economic Cooperation Economies: Assessment of a Multiyear Building Capacity Project. Antibiotics (Basel, Switzerland), 11(8), 1022. https://doi.org/10.3390/antibiotics11081022
10. https://www.cidrap.umn.edu/data-sharing-initiative-aims-help-fight-against-antibiotic-resistance
11. Okolie, O. J., Igwe, U., Ismail, S. U., Ighodalo, U. L., & Adukwu, E. C. (2022). Systematic review of surveillance systems for AMR in Africa. The Journal of antimicrobial chemotherapy, 78(1), 31–51. https://doi.org/10.1093/jac/dkac342
12.Moura, P., Collineau, L., Sandberg, M., Tomassone, L., De Meneghi, D., Norström, M., Bennani, H., Häsler, B., Colomb-Cotinat, M., Bourély, C., Filippitzi, M. E., Mediouni, S., Boriani, E., Asaduzzaman, M., Caniça, M., Aenishaenslin, C., & Alban, L. (2023). Users’ perception of the OH-EpiCap evaluation tool based on its application to nine national antimicrobial resistance surveillance systems. Frontiers in public health, 11, 1138645. https://doi.org/10.3389/fpubh.2023.1138645
14. Yadav, S. K., Shrestha, L., Acharya, J., Gompo, T. R., Chapagain, S., & Jha, R. (2023). Integrative Digital Tools to Strengthen Data Management for Antimicrobial Resistance Surveillance in the “One Health” Domain in Nepal. Tropical medicine and infectious disease, 8(6), 291. https://doi.org/10.3390/tropicalmed8060291
15. Carter, D. J., Byrne, M. K., Djordjevic, S. P., Robertson, H., Labbate, M., Morgan, B. S., & Billington, L. (2023). Personal Data for Public Benefit: The Regulatory Determinants of Social Licence for Technologically Enhanced Antimicrobial Resistance Surveillance. Journal of law and medicine, 30(1), 179–190.
