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Microbiology laboratories in Latin America: joining efforts to monitor antimicrobial resistance

Organization(s)

Pan American Health Organization/World Health Organization

Country (ies) and institutions

Argentina - Instituto Nacional de Enfermedades Infecciosas (INEI) ANLIS - “Dr Carlos G. Malbrán”, Bolivia, Instituto Nacional de Laboratorios de Salud (INLASA), Brasil - Coordinación Nacional de Laboratorios del Centro Nacional de Epidemiología (CGLAB/CENEPI), Chile - Instituto de Salud Pública, Ministerio de Salud, Colombia - Instituto Nacional de Salud, Ministerio de Salud, Costa Rica - Centro Nacional de Referencia de Bacteriología del INCIENSA, Cuba - Instituto de Medicina Tropical “Pedro Kouri”, Ecuador - Hospital Vozandes, El Salvador - Laboratorio Central Dr. Max Bloch, Guatemala - Laboratorio Nacional de Salud, Honduras - Laboratorio Central de Microbiología de la Secretaria de Salud, México - Instituto de Diagnóstico y Referencia Epidemiológica (InDRE), Nicaragua - Centro Nacional de Diagnóstico y Referencia (CNDR), Paraguay - Laboratorio Central de Salud Pública, Perú - Instituto Nacional de Salud, Uruguay - Departamento de Laboratorios de Salud Publica, Venezuela - Instituto Nacional de Higiene “Rafael Rangel” y Hospital Vargas. Supra National Reference Centers Argentina - Instituto Nacional de Enfermedades Infecciosas (INEI) ANLIS - “Dr Carlos G. Malbrán”. Canada – National Microbiology Laboratory, Winnipeg. Public Health Agency of Canada. Other Partners: USAID, American Society for Microbiology, Centers for Disease Prevention and Control. Pan American Health Organization/World Health Organization (PAHO/WHO). Diagram to describe how institutions were related to each other. (If available) http://www.southsouthcases.info//ttssc/web/uploads/diagrams/e5c9bbf2e7264f4773611d5a8b4b41a22b7baa3d.jpg

Overview

In the mid-1990s, the PAHO, designed and implemented a program aimed at strengthening microbiology laboratories for the identification of bacteria and testing susceptibility to antimicrobial drugs. The program had two main objectives: 1) to improve surveillance of antimicrobial resistance; and 2) to improve the national capacity of countries in the Americas to address antimicrobial resistance. South-to-south collaboration has been used as a successful strategy to strengthen the capacity of national institutions by supporting technical country-to-country collaboration.

Background and set-up

Having recognized that drug resistance posed a serious threat to public health in the Region, in 1996, the PAHO, designed and implemented a program aimed at strengthening microbiology laboratories for the identification of bacteria and testing susceptibility to antimicrobial drugs. Partners engaged in the activity because of their concern on antimicrobial resistance which poses a challenge for the control of infectious diseases. The participating countries, as condition prior to its participation in the Network, committed to having a center that would act as coordinator of the national network, which in turn would be made up of sentinel institutions. In the majority of the countries the coordinating institution is the National Reference Center specialized in the topic of the network. Its function is: 1. Organize and coordinate the program for the monitoring of the antimicrobial susceptibility of the pathogens of importance in public health; 2. Serve as referral and cross-referral institution, which it consists of confirming the diagnoses, conducting complementary studies, and clarifying every doubt that it arises from the activities that the national participants of the network carry out; 3. Organize and carry out the Management of Quality (internal quality control, audit and external evaluation of the performance) in order to guarantee the quality of the diagnoses and the determination of the susceptibility to the antimicrobial drugs. This includes the dictation of standards for quality assurance, the supervision in order to ensure that these standards are met, the distribution of strains for quality control of the antibiogram and the execution of programs of performance evaluation for the institutions participating in the network; 4. Standardize the techniques of diagnosis, serotyping, and antimicrobial susceptibility; 5. Train technical personnel and professionals of the institutions participating in the network; 6. Organize and maintain a strain bank; 7. Consolidate periodically the information provided by the sentinel institutions, analyze it, and disseminate it. The participating countries, as condition prior to its participation in the Network, committed to having a center that would act as coordinator of the national network, which in turn would be made up of sentinel institutions. In the majority of the countries the coordinating institution is the National Reference Center specialized in the topic of the network. Its function is: In turn, the sentinel institutions have the following functions: 1. Carry out the control and periodic maintenance of the equipment; 2. Meet the biosafety standards; 3. Follow the standards of quality control, including the standards of the “National Committe for Clinical Laboratory Standards”, for the realization of antibiograms by the methodology of Kirby Bauer; and 4. Disseminate the findings that are carried out. The incorporation of the countries has been progressive from the beginning of the network in 1996 (eight the countries) to date final of the study (2004, 17 the countries), in 1 addition within every country there was being expanded the number of center participating in the national surveillance network, as there is shown in Table 7. Supranational quality control was carried out by the `National Laboratory for Enteric Pathogens` (NLEP) of Canada. Quality control is carried out annually through the shipment of a strain panel in blind person to the national reference laboratory. Additionally, the National institute of Infectious Diseases ANLIS, “Dr.C.G. Malbran”, Argentina, sends a panel of 10 unknown strains, enteric and non-enteric, twice a year to Bolivia, Ecuador, El Salvador, Guatemala, Paraguay, Peru, Nicaragua and the Dominican Republic.

The partnership

The participating countries, as condition prior to its participation in the Network, committed to having a center that would act as coordinator of the national network, which in turn would be made up of sentinel institutions. In the majority of the countries the coordinating institution is the National Reference Center specialized in the topic of the network. Its functions are: 1. Organize and coordinate the program for the monitoring of the antimicrobial susceptibility of the pathogens of importance in public health; 2. Serve as referral and cross-referral institution, which it consists of confirming the diagnoses, conducting complementary studies, and clarifying every doubt that it arises from the activities that the national participants of the network carry out; 3. Organize and carry out the Management of Quality (internal quality control, audit and external evaluation of the performance) in order to guarantee the quality of the diagnoses and the determination of the susceptibility to the antimicrobial drugs. This includes the dictation of standards for quality assurance, the supervision in order to ensure that these standards are met, the distribution of strains for quality control of the antibiogram and the execution of programs of performance evaluation for the institutions participating in the network; 4. Standardize the techniques of diagnosis, serotyping, and antimicrobial susceptibility; 5. Train technical personnel and professionals of the institutions participating in the network; 6. Organize and maintain a strain bank; 7. Consolidate periodically the information provided by the sentinel institutions, analyze it, and disseminate it.

Lessons learned

- The Network of Monitoring and Surveillance has increased its ability to detect, monitor, and arrange for the antibiotic resistance during the period 2000–2008. Such greatest capacity is sustained by the growing number of the countries participating in the Network and the increase in the number of isolations. As an example, in 2000, 72,000 strains were analyzed, and in 2004, more than double, 158,693. The information from the countries can indicate how the resistances vary geographically and over time. The constant monitoring of the prevalence of resistances through this Network is an excellent tool to guide the resources efficiently. - The steady increase of the number of strains studied is especially at the expense of the increase in the number of strains of hospital origin, surely by the greatest activity and surveillance of hospital infection. - From the geographical perspective, the subregion that more `specimens` contributes to the Network is the Southern Cone, followed by the Andean Area, and finally Central America and Mexico. This degree of participation could be the result of the greatest degree of development of the laboratory networks in the Southern Cone. - With regard to the participation of the countries, these contribute to the Network a very high or very low number of samples (the medium per country are 619 samples per year; percentile 25 is in 62, and the median in 184), that they can turn out non-representative of the its countries. - The participation of the large federal countries as Mexico and Brazil is limited; a strong political commitment is condition necessary for guaranteeing the increase in its participation, so that they can offer data that are representative of the national situation. - The network follows rigorous quality control that guarantees the laboratory results. However, it is necessary maintaining the support for the `continuous quality improvement` of the laboratories, accompanied by corresponding financing. - It is necessary to standardize antibiotics facing those which the countries study the resistances of a given microorganism, and, in addition, these antibiotic have to be in accordance with the recommended by the guides of clinical practice. Otherwise, there will exist a gap among the prescribers of antibiotics and results of the monitoring to the antimicrobial resistances. - Research on the ratios by which the some countries have rates of such low resistances, while others have them very high, will offer a very necessary orientation for determining the causes of the resistances, and possible interventions for preventing the development of the same.

Complementarity with North-South cooperation

This case-study permits to appreciate the usefulness of the surveillance network to antibiotics, not only in the strengthening of the national laboratory networks, but also as generators of evidence for decision-making. The analysis of the magnitude of the resistances, and its temporary trend have to be considered in the preparation of guides on the empirical use of antibiotics. Furthermore, the results can be used to predict the resistance development and contribute to the intervention prioritization to contain given resistances in specific microorganisms. The standardization of the rates permits to identify those countries with greater magnitude of resistances, in comparative terms with others, so that the efforts of the international organizations can prioritize those countries with greater resistance charge. USAID provided the necessary funds for the operational structure of the Network, publication of guidelines, technical meetings and direct technical support of the countries.

How to share

The Network of Monitoring/Monitoring of the AMR has shown a stability in its operation over time, improving the monitoring of quality standards, increasing the number of the participating countries, the number of microorganisms included in surveillance and the number of isolations processed for sensitivity study. Serious necessary to obtain a greater knowledge of the origin of the samples, and its distribution, so that there could be considered representative of the different national situations. This is particularly complex for those great land area countries, as Brazil and Mexico. Parallel to improving surveillance of antimicrobial resistance, efforts began to promote policy approaches to contain the problem. Following a TAG recommendation, Model Clinical Guidelines for the Treatment of Infectious Diseases were developed by infectious diseases experts from the Region, and the national adaptation of the Guidelines was promoted and supported. During the time of operation of the network, the following products have been obtained and disseminated: g. Drafting and publication of an annual report on the resistance to antibiotics in the participating countries. h. Development and implementation of a program for performance evaluation to identify microorganisms and determine its susceptibility to antibiotics. i. Creation of a page on the resistance to the antimicrobial drugs in the site of Internet of PAHO. j. Periodic implementation of workshops on bacterial identification and tests of sensitivity, directed to strengthen the technical capability of the participating countries. k. Development of a protocol to evaluate the cost of the hospital infections, applied in Bolivia, El Salvador, Ecuador, Guatemala, Paraguay, and Peru. l. Production of material for training of professionals of the laboratories and distribution of printed information to the participating institutions.

Duration

(YY-mm-dd) 2000-01-01-- (YY-mm-dd) 2011-09-30

Budget

File

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Image

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Name of Primary Contact Person/s

Pilar Ramon-Pardo

Title of Primary Contact Person/s

Advisor on Antimicrobial Resistance

City and country

Washington DC, USA Contact Email/s ramonpap@gmail.com

Telephone/s

Key players

Jorge Matheu, Specialist on AMR, OPS, #Washington. 202 974 3487 '(a confirmar). Marcelo Gal;as Alejandra (ver disolucion)