Clinical microbiology laboratories in low-resource settings, it is not only about equipment and reagents, but also good governance for sustainability

Antimicrobial resistance control activities at a tertiary hospital in a low-resource setting: an example of Queen Elizabeth Central Hospital in Malawi

Background

Addressing AMR has been most problematic in low- and middle-income countries, which lack infrastructure, diagnostic capacity, and robust data management systems, among other factors. The implementation of locally-led efforts in a low-income country to develop sustainability and build capacity for AMR control within the existing infrastructure has not been well documented.

Methods

We detail current AMR control initiatives at Queen Elizabeth Central Hospital, a tertiary referral government hospital in Malawi with limited resources, and present the activities accomplished to date, lessons learned, and challenges ahead.

Results

The key areas of AMR control initiatives that the group focused on included laboratory diagnostics and surveillance, antimicrobial stewardship, infection prevention and control, pharmacy, leadership, education, and funding.

Discussion

The hospital AMR Control Working Group increased awareness, built capacity, and implemented activities around AMR control throughout the hospital, in spite of the resource limitations in this setting. Our results are based on the substantial leadership provided by the working group and committed stakeholders who have taken ownership of this process.

Conclusion

Limited resources pose a challenge to the implementation of AMR control activities in low- and middle-income countries. Leadership is central to implementation. Future efforts will need to transition the initiative from an almost fully personal commitment to one with wider engagement to ensure sustainability.

Enhancing cell resistance for production of mixed microbiological reference materials with Salmonella and coliforms by freeze-drying

The reference material (RM) is a technical requirement for the quality assurance of analytical results and proficiency tests or interlaboratory comparisons. Microbiological RMs are most available in the dehydrated form, mainly by freeze-drying, and maintaining bacterial survival after preparation is a challenge. Thus, obtaining the most resistant cells is essential. Considering that bacteria present cross-response to dehydration after being submitted to an array of stress conditions, this study aimed to evaluate the influence of growth conditions on enterobacteria for the production of mixed microbiological RMs by freeze-drying in skim milk powder. Salmonella enterica serovar Enteritidis, Cronobacter sakazakii, Escherichia coli, and Citrobacter freundii were grown in a minimal medium with 0.5 M NaCl and 0 to 5.0 mM of manganese sulfate (MnSO4) until stationary phase. Salmonella Enteritidis presented an increased resistance to dehydration in the presence of Mn, while C. sakazakii was the most resistant to freeze-drying and further storage for 90 days. Mixed microbiological RMs were produced by freeze-drying and containing Salmonella Enteritidis and coliforms in skim milk powder with 100 mM of trehalose and the Salmonella survival rate was 91.2 to 93.6%. The mixed RM was stable after 30 days at -20 °C, and Salmonella and coliforms were detected by different methods being, the Rambach Agar the best for the bacterial differentiation. The results showed that the culture conditions applied in this study resulted in bacterial cells being more resistant to dehydration, freeze-drying, and stabilization for the production of mixed microbiological RMs more stable and homogeneous.

Unbiased antimicrobial resistance prevalence estimates through population-based surveillance

BACKGROUND

Current antimicrobial resistance surveillance (AMR) is mainly laboratory-based. This approach can have inherent biases given the potential for selective specimen submission for microbiological analysis, and for its inability to map antibiotic susceptibility test results to a clinical syndrome.

OBJECTIVES

To discuss the need for population-based surveillance of AMR, and highlight the pros and cons of threshold surveys.

SOURCES

Studies on methodology for AMR surveillance published in the last 10 years, obtained through a PubMed search on antimicrobial resistance (all fields) and surveillance/method (MeSH term).

CONTENT

We discuss the use of threshold surveys to overcome the challenge of sample size in population-bases AMR surveys, which are a suitable approach in both low- and high-resource settings.

IMPLICATION

Scale up in the use of population-based threshold survey on the prevalence of AMR will provide necessary information to triangulate the data from routinely-reported laboratory-based AMR surveillance at the local, national and global level.