Abstract
This review provides an update on the factors fuelling antimicrobial resistance and shows the impact of these factors in low-resource settings. We detail the challenges and barriers to integrating clinical bacteriology in hospitals in low-resource settings, as well as the opportunities provided by the recent capacity building efforts of national laboratory networks focused on vertical single-disease programmes. The programmes for HIV, tuberculosis and malaria have considerably improved laboratory medicine in Sub-Saharan Africa, paving the way for clinical bacteriology. Furthermore, special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings. Traditionally, clinical bacteriology laboratories have been a part of higher levels of care, and, as a result, they were poorly linked to clinical practices and thus underused. By establishing and consolidating clinical bacteriology laboratories at the hospital referral level in low-resource settings, routine patient care data can be collected for surveillance, antibiotic stewardship and infection prevention and control. Together, these activities form a synergistic tripartite effort at the frontline of the emergence and spread of multi-drug resistant bacteria. If challenges related to staff, funding, scale, and the specific nature of clinical bacteriology are prioritized, a major leap forward in the containment of antimicrobial resistance can be achieved. The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories. The future clinical bacteriology laboratory in a low-resource setting will not be an “entry-level version” of its counterparts in high-resource settings, but a purpose-built, well-conceived, cost-effective and efficient diagnostic facility at the forefront of antimicrobial resistance containment.
Highlights
Jan Jacobs 1,2*, Liselotte Hardy 1, Makeda Semret 3, Octavie Lunguya 4,5, Thong Phe 6, Dissou Affolabi 7, Cedric Yansouni 3 and Olivier Vandenberg 8,9,10
Special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings
The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories
Summary
In view of the growing problem of AMR, the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE) recently (2015) joined forces. - Guidance for sampling (indications, specimen, timing, precautions, transport - Establish and implement sample rejection criteria - Timely transport, organize reception, routing and tracking of the samples in the laboratory - Assure accurate state-of-the-art processing of submitted samples - Prioritizing samples for quick processing and reporting - Performing rapid diagnostic testing (biomarkers, molecular and antigen-based diagnosis) - Timely reporting of actionable intermediate and preliminary results - Enhanced and clinically relevant final report - “Liaison” with clinicians and nursing staff in high risk wards (intensive care unit) - Supplementary AST testing for newly introduced antibiotics - Referral of samples/isolates to reference laboratories for advanced level testing ◦ Information Technology (IT)* - Reporting of preliminary results: text messaging, electronic messages - Reporting of final results: cascade/selective reporting, treatment-related comments - Digital clinical decision support systems at the bed-side or point-of-care - Transmission of AST data useful for pre-authorization of antibiotics to pharmacy - Transmission of AST data useful to guide review of antibiotics treatment - Creating prompts “pop-ups” e.g., “bug-drug mismatch” - Surveillance data, cumulative antibiogram report, antibiogram - Broad interventions and Pharmacy-driven interventions. Adapted from Nkengasong et al [41], Barbé et al [92]; Alemnji et al [93], Nkengasong et al [94], Andiric et al [95], WHO [96]; Carter et al [97], and Sayed et al [98]
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