1. Surveillance of Antimicrobial Resistance and Use In The Community Methodological Issues Thatte UM, Kulkarni RA, Holloway K, Sorenson T, Koppikar GV, Shinkre N, Chaudhury RR

2. Background  Temporal relationship between antimicrobial use and resistance in hospital setting shown  No robust surveillance system for monitoring AMR and drug use in community

3. Aim Can we develop a surveillance system to measure AMR and drug use in the community, study the temporal relationship and identify areas of interventions? Objectives  Resistance in E.coli isolated from stools in the community  Use of antimicrobials in the health facilities and drug shops attended by same community  Compare drug use patterns with antimicrobial resistance

4. E-ward 4.5 lakh population 1 tertiary care hospital 12 municipal dispensaries (MD) 115 Private practitioners (GP) 75 Chemists Representative of population Municipal ward limits All types of health care facilities URBAN representation

5. Setting Resistance  Tertiary hospital  Municipal dispensaries  Private Practitioners (GPs) Drug Use  Tertiary hospital  Municipal dispensaries  Private Practitioners (GPs)  Chemist shops Prospective, time series study 12 months (+5months)

6. Which sample for resistance surveillance? Urine ?  Collection easy  Normally sterile: pick-up poor  Infected samples: how representative for surveillance? Throat swab ?  Collection more difficult: consent from volunteer difficult  Approximately 25% pick-up (need larger sample size)

7. Which sample for resistance surveillance? Stools?  Collection easy  Almost 80-100% pick-up (need smaller sample size)

8. Which sample for resistance surveillance? Stools?  Sample needs to be brought next day: compliance?  Use a rectal wipe – cultural issues  Use samples from diarrhea patients?  Variable incidence of diarrhea: some seasons 1-2 patients per week  Use non-diarrhea samples as well  Patient may take a dose of antimicrobial before giving stool sample  More patients who receive antimicrobials agree to give stool samples compared to those not receiving: data skewed

9. Samples for resistance surveillance Institutional Ethics Committee permission Stool samples (200 per month) obtained after informed consent, record of antibiotic given Tertiary hospital1 Municipal dispensaries 9/12 General practitioners (private)90/115

10. Samples for resistance surveillance  diarrhea/non-diarrhea  adults and children,  antibiotic naïve and those who received antibiotics

11. Resistance patterns at different facilities Diarrhea-No diarrhea Amoxycillin Dispensary OPD GP

12. Dispensary OPD GP Resistance patterns at different facilities Diarrhea-No diarrhea Nalidixic acid

13. % resistance across facilities %

14. Resistance testing NCCLS guidelines using Kirby Bauer Disk Diffusion Method The following 11 antibiotics were tested AmoxycillinNalidixic acid AmpicillinNorfloxacin Ciprofloxacin Furazolidine Doxycycline Cefotaxime Cotrimoxazole Gentamicin Cephalexin Importance of QC

15. Drug Use Studies 300 antibiotic prescriptions per month per facility Tertiary hospital (OPD)1 Municipal dispensaries (MD) 9/12 General practitioners: (GP)90/115 Chemists: 63/75 Convenience sampling Prescription audit Exit interviews

16. Drug Use Studies  Pharmacy Records (Chemists and GPs) not accessible  Private Sector not as cooperative: implications for a sustainable surveillance system  Taking informed consent from patients  Improved patient knowledge as more information given to patients by dispensers  Chemist shops: very few (<5%) patients dispensed antibiotics without prescriptions: effect of field officers presence?

17. Resistance Pattern and Use Cotrimoxazole

18. Resistance Pattern of Nalidixic acid and Quinolone Use

19. Combined - Drug use vs. resistance Cotrimoxazole

20. Designing an intervention  Whom to target?  Type of intervention: difficulties in private sector  Municipal dispensaries: use related to stock availability  Sustainability of intervention in private sector

21. Data management  Computerisation at the beginning: inputs from experts  Training of field staff

22. Areas for Research  Interventions: sustainable, effective in community, private health sector  Will any other organism/source be more convenient/representative of resistance in community  Influence of other sources of antibiotic intake