1. ANTIMICROBIAL USE AND RESISTANCE SURVEILLANCE PILOT PROJECT – LESSONS FROM THE DURBAN SITE
Gray AL, Essack SY, Deedat F, Pillay T, van Maasdyk J, Holloway K, Sorensen TL, Sturm AW Dept. Pharmacology and Dept. Medical Microbiology, Nelson R Mandela School of Medicine, School of Pharmaceutical Sciences, Univ. KwaZulu-Natal, Durban, South Africa, WHO/EDM, Geneva

2. Abstract
 Problem Statement: The World Health Organization’s global strategy for containing antimicrobial resistance recommends the development of methodologies that will enable developing countries to identify and track resistance trends in specific infections and geographical locations. Standard methods for such surveillance systems do not exist for resource-constrained settings.
Objectives: To investigate the association between antibiotic use and resistance over time in respiratory tract infections in the Inner West metropolitan area of Durban.
Design: Retrospective, time series analysis of antimicrobial use data and antimicrobial resistance of selected isolates.
Setting and population: 7 randomly selected private pharmacies, 7 convenience sampled private dispensing practitioners and 7 randomly selected state-operated nurse-managed primary health care clinics.
Methods: Antimicrobial use data were obtained from prescription records at sites representing a broad spectrum of socio-economic conditions and prescriber types. Sputum specimens were obtained from consenting patients presenting with self-reported cough with or without fever at 4 sites in the selected geographical locale. Cultures positive for Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis were subjected to MIC determinations against ampicillin, erythromycin, chloramphenicol, cotrimoxazole and ciprofloxacin by means of agar dilution. NCCLS breakpoints were applied to determine resistance.
Outcome measures: Percentage of patients seen (or prescriptions dispensed) in which an antimicrobial was prescribed; antimicrobial usage in Defined Daily Doses per 100 patients seen; percentage susceptibility of selected isolates.
Results: High usage of older antimicrobial agents was seen in public sector clinics and lower usage of a wide range of agents, including newer broad-spectrum antimicrobials, in the private sector. Percentage resistance of selected isolates by time series per quarter showed an decreasing level of resistance amongst pneumococci to ampicillin and erythromycin, but continuously total resistance to cotrimoxazole. Increasing trends in resistance to ampicillin were shown amongst H influenzae, but decreasing trends in resistance to cotrimoxazole.
Conclusions: Although no direct relationship between resistance levels and antimicrobial usage could be shown, the feasibility of establishing a system to generate data of this sort was demonstrated. Further analysis over time is planned.
Study funded by: World Health Organization.

3. Background
In September 2001 the WHO released the Global Strategy for Containment of Antimicrobial Resistance (WHO/CDS/CSR/DRS/2001.2)
This document identified 67 interventions targeted at different groups
It also identified the need for linked surveillance of antimicrobial resistance and use, in order to assess these interventions
Not clear how to achieve this in resource-constrained setting

4. Objectives
To investigate the association between antibiotic use and resistance over time in respiratory tract infections in the Inner West metropolitan area of Durban, South Africa

5. Methods – resistance Sputum specimens 4 convenience sampled sites
consenting patients with self-reported cough, with or without fever
4 convenience sampled sites
Public and private sector
Standard laboratory work-up
Selective cultures for:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
MIC determinations
ampicillin, erythromycin, chloramphenicol, cotrimoxazole and ciprofloxacin
agar dilution
standard NCCLS breakpoints

6. Methods – antimicrobial use
Retrospective prescription audit (2 weeks’ Rx per month)
7 randomly selected private pharmacies (stratified by socio-economic status of area; data from original prescriptions)
7 convenience sampled private dispensing practitioners (stratified by socio-economic area; data from clinical records)
7 randomly selected primary health care clinics (stratified by size; data from daily clinic registers)
Data analysis
% patients seen (or prescriptions dispensed) in which an antimicrobial was prescribed
antimicrobial usage in Defined Daily Doses per 100 patients seen (clinics and doctors) or prescriptions dispensed (pharmacies)
% susceptibility of selected isolates - all by time series

7. S. pneumoniae – resistance (ciprofloxacin not tested)

8. H. Influenzae – resistance (no resistance to erythromycin or ciprofloxacin)

9. Antimicobial use – overall
Facility type
Total patients seen or prescriptions dispensed
Antimicrobial-containing prescriptions
% AM Rx
Pharmacies (prescriptions)
19 979
2 400
12.0
Clinics
84 390
14 096
16.7
Dispensing practitioners
23 420
3 003
12.8

10. Antimicrobial use - cotrimoxazole
Winter

11. Antimicrobial use - quinolones
Winter

12. Antimicrobial use – all antimicrobials
Winter

13. Conclusions and Acknowledgements
Although no direct relationship between resistance levels and antimicrobial usage could be shown, the feasibility of establishing a system to generate data of this sort was demonstrated
Given the differences in antimicrobial use patterns in different settings, interventions to contain the development of resistance will have to be carefully tailored for each setting
Thanks to: WHO/EDM for funding this pilot project, the fieldworkers and laboratory staff, the staff at the facilities, for allowing us access to their patients and their data, the patients who provided sputum samples