Surveillance of Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU)

Surveillance of AMR and AMU is crucial for understanding trends, informing policies, and guiding interventions to combat the global threat of antimicrobial resistance in food animals, the environment, and humans. India has several AMR surveillance programs, but there is an urgent need to integrate them for effective surveillance and mitigation through a One Health approach. Additionally, the association of antibiotic use in animals with the emergence of antibiotic resistance in humans needs further study.

Introduction

Surveillance is the systematic ongoing collection, collation and analysis of data, and the timely dissemination of information to relevant stakeholders, particularly those who are in a position to take action. Antimicrobial resistance (AMR) surveillance and monitoring -tracks changes and trends in AMR pathogens and resistant determinants. One Health approach will help to integrate findings of antibiotic use (AMU) in animals, humans, plants and the environment. This involves sharing data and information across sectors for a more effective and coordinated response to tackling AMR.

Objectives of AMR surveillance in livestock, humans and environment

Document prevalence of antibiotic-resistant bacteria over time and geography.
Understand AMR transmission dynamics across livestock, fisheries, the environment, and humans.
Forecast the emergence of new drug-resistant bacteria.
Evaluate epidemiological clones of AMR pathogens.
Understand the persistence of drug-resistant pathogens.
Plan, implement, and evaluate treatment strategies.
Conduct training and awareness programs on AMR stewardship.

Methods of AMR Surveillance

Laboratory-based: Monitoring resistance in clinical isolates from human and animal health.
Sentinel Surveillance: Sentinel surveillance: Collecting data from selected healthcare facilities to identify trends.
Genomic Surveillance:Genomic surveillance of AMR bacteria by using Whole-genome sequencing and metagenomics approach for identifying resistance genes in pathogens.
Environmental Surveillance: Environmental surveillance: Monitoring resistance in water, soil, and food sources.

Global Initiatives

WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS): A global effort to standardize AMR surveillance.

European Antimicrobial Resistance Surveillance Network (EARS-Net): A European initiative to monitor AMR in human medicine.

National Antimicrobial Resistance Monitoring System (NARMS) in USA

The International FAO Antimicrobial Resistance Monitoring (InFARM) system

National AMR Surveillance Programs

NARS-Net (NCDC): The National AMR surveillance network (NARS-Net) – by NCDC for Humans based on Clinical data
AMRSN (ICMR): Antimicrobial Resistance Surveillance and Research Network (AMRSN) –by ICMR for Humans based on Clinical data
AINP-AMR (ICAR): All India Network project on AMR in livestock and fisheries (AINP-AMR) by ICAR for healthy livestock and fisheries sector (No clinical surveillance)
National One Health Mission: National One Health Mission program- integration of human, animals, plants and environment
INFAAR (ICAR & FAO): AMR Surveillance Data: In India, ICMR, NCDC and ICAR organisations have separate network projects for AMR surveillance in both humans and livestock sector. For example, National AMR Surveillance network (NARS-Net) was established in 2013 to determine the magnitude and trends of AMR in humans in different geographical regions of the country.

Laboratory techniques employed for AMR surveillance

Phenotypic Methods: Phenotypic Antibiogram methods (AST): Disc diffusion, Automated AST systems (BD-M50, Sensititre and Vitek) as per CLSI 2024 breakpoints of MICs for Grams negative and Grams positive bacteria
Genomic Methods: Genomic surveillance methods: Whole genomic sequencing and analysis, metagenomics, amplicon sequencing, etc for ARGs, global clones of staph aureus, ESBLs etc

Methods for AMR surveillance data analysis

Spatial Analysis Techniques:

Mapping:Thematic maps can be created using ArcGIS or Epi info TM to visually represent the spatial distribution of antibiotic-resistant pathogens, clinical cases, antibiotic use pattern, antibiotic resistance pattern, etc to understand the prevalence of AMR in different regions.
Hotspot Analysis: A hotspot can be defined as an area that has higher concentration of events compared to the expected number. Hotspot analysis is a spatial analysis and mapping technique used for identification of clustering of spatial phenomena.
Spatial Autocorrelation: It is mainly used to identify whether neighbouring regions exhibit similar outbreak of drug-resistant pathogens or AMR patterns.
Buffer Analysis: It is used particularly to study the impact of certain features (e.g., urban areas, hospitals, livestock farms) on AMR prevalence.
Cluster Analysis: The method of identifying similar groups of data in a large dataset is called clustering or cluster analysis.
Heatmap Analysis:heat map analysis method is being used specifically to map the antibiotic resistance gene repertoire or antibiotic resistance profiles in various settings such as humans, livestock, water and environment.