Novel strategies and tools for antimicrobial resistance surveillance

Indonesian project leader: Dr Ida Parwati, Padjadjaran University Dutch project leader: Prof. Menno de Jong, University of Amsterdam

Antimicrobial resistance (AMR) represents one of the gravest threats to global health. A return to the pre-antibiotic era is imminent unless efforts to combat AMR are prioritized. Key to such efforts is adequate surveillance of AMR at local levels in order to inform empirical antimicrobial treatment and monitor efforts to control AMR and to inform policy at national and international levels. Conventional AMR surveillance is costly, logistically challenging (especially in settings with limited resources) and usually does not provide relevant timely information that can optimize individual patient care. Furthermore, microbiology capacity and quality is often insufficient to support  reliable AMR surveillance. Novel approaches are thus needed that require minimum resources and produce a maximum yield in terms of quality and relevant data. The mission of our project is to achieve this aim by combining an efficient sampling strategy – Lot Quality Assurance Sampling (LQAS) – with internet-based capacity-building and e-learning: the Telemicrobiology approach.

LQAS is a classification tool originating in industry in which the predefined prevalence of a particular outcome should lead to a responsive action (e.g. rejection of a production batch, or in the case of AMR, adjustment of empirical antimicrobial treatment guidelines). This approach requires only small sample sizes, hence improving feasibility and the speed at which relevant AMR data can be acquired. The Telemicrobiology approach combines interactive virtual ‘lab rounds’ between peers, using a designated high-resolution digital imaging tool and the internet with e-learning in a blended continuous learning approach that combines workshops and digital teaching resources.

Telemicrobiology: virtual lab rounds between microbiology laboratories in Asia and the Netherlands Photo: Menno de Jong

The objective of the project is to validate, optimize and implement the use of LQASbased AMR surveillance, supported by Telemicrobiology, as a feasible and cost-effective strategy to inform local antimicrobial stewardship programmes and to estimate AMR prevalence. This objective will be addressed in two closely related PhD projects. One focuses on epidemiology and mathematical modelling, addressing the validation and optimization of LQAS-based surveillance versus conventional surveillance as well as issues such as bias introduced by hospital-based surveillance or negative cultures. The second PhD project focuses on clinical and microbiological aspects, including the impact of LQAS-based surveillance data on appropriateness of empirical therapy, the genetic basis of AMR, and the impact of Telemicrobiology on laboratory capacity and quality. The surveillance studies will target urinary tract infections caused by Escherichia coli and Klebsiella pneumonia, and will be performed at primary, secondary and tertiary health care facilities in Bandung (Java) and Medan.

Besides providing a wealth of data on AMR and its consequences, this project will potentially deliver a strategy for AMR surveillance which not only is feasible in settings with limited resources, but which may prove valuable in any setting worldwide. In addition, Telemicrobiology approaches may provide much-needed tools for sustainable capacity-building in microbiology, which can be applied in networks of laboratories in Indonesia, Southeast Asia, and globally.