2. Methodological challenges for AMR surveillance programmes Gous AGS, Pochee E School of Pharmacy Medical University of Southern Africa

3. Introduction  Background on the AMR surveillance programme at Brits/Madibeng District  Challenges in setting up a District- Based AMR Surveillance Programme  What are the challenging methodological issues in AMR surveillance in communities?  Which methods questions should be included in a future research agenda in AMR surveillance in communities?

4. Background  Aim  To set up a district-based surveillance programme of antimicrobial use (for all clinical conditions)  and resistance of Escherichia coli in the urine of patients with suspected uncomplicated urinary tract infection  Requirements  100 E. coli isolates per month  30 antimicrobial-containing prescriptions per month per collection site

5. Background Case definition Inclusion criteria  Urine specimens will be obtained from women with the following signs and symptoms:  Dysuria  Urgency and frequency of micturition  Suprapubic pain, feeling of fullness or a sensation of pressure

6. Background Exclusion criteria  All male patients  Patients younger than 13 years  Patients with recurrent UTIs  Recurrent UTIs are defined as proven UTIs in the past six months  Patients who were hospitalised in the past month  Patients on treatment for bacterial infections in the past month  Patients with abnormal vaginal discharge or genital ulceration

7. Background Participating facilities in the Brits/Madibeng District, North West Province, South Africa (see map)  Outpatient and emergency departments of Brits Hospital, a public district hospital  Six primary health care clinics  Three clinics under the North West Department of Health  Two clinics under the Brits/Madibeng City Council  One Non-Governmental Organisation (NGO) clinic  Five private community pharmacies  Five private medical practitioners

8. Map of the study area South Africa

9. Challenges during set-up and implementation 1.Existing surveillance programmes are confined to academic and tertiary health care institutions 2.Finding community partners 3.Commitment of different stakeholders varies

10. Challenges during set-up and implementation (continued) 4.The logistics of data collection were complicated by:  The distance between the different sites  Remoteness of some sites  Lack of regular transport 5.Approval and start of the programme was delayed by:  Health management changes  Demarcation of districts  New appointments in management positions  Sensitivity towards research 6.Establishment and ongoing restructuring of the National Laboratory Services

11. Challenges during set-up and implementation (continued) 7.Detailed patient information and consent forms had to be designed and translated into several languages 8.It was a challenge to plan the study without knowing what data sets may be needed to ensure appropriate data collection to identify shortcomings in antimicrobial use as well as consumption over time at all levels of the health system

12. Challenges during set-up and implementation (continued) 9.Training sessions had to be postponed or repeated due to  Location of the different sites  Lack of transport  Staff workload: prevents the release of staff to attend the sessions  Staff turnover

13. Challenging methodological issues Sampling of urine specimens  Identifying and enrolling suitable patients  Inclusion criteria  Exclusion criteria  Antenatal patients  Obtaining consent  Workload  Dedicated people  Obtaining specimens  Patient education  Antenatal patients  Storage and transport of specimens  Processing  The use of culture and sensitivity results to guide therapy

14. Challenging methodological issues (continued) Antimicrobial use  Acute vs chronic prescriptions  TB  PC prophylaxis  Access to patient information  Patients retain their files  Diagnosis not provided on private prescriptions  Prescription journals  Require staff with knowledge on antimicrobial use  Each primary health care worker has his/her own prescription journal  Doctors do not record their prescriptions in a prescription journal, only on the patient’s file

15. Which methods questions should be included in future research?  The need for consent  Inclusion criteria  Modifying standard procedures of processing specimens  Acute vs chronic prescriptions  Data sets  Intervention on usage of drugs that will not impact on UTI treatment  Collecting more data than what is required for surveillance  What to do if there is a need to intervene during initial phase of the surveillance programme