Laboratory-based versus population-based surveillance of antimicrobial resistance to inform empirical treatment for suspected urinary tract infection in Indonesia.

Adhi Kristianto Sugianli,Davida S. Smyth,Frank van Leth,Franciscus Ginting,Constance Schultsz,Menno D. de Jong,R. Lia Kusumawati,Ida Parwati

doi:10.1371/journal.pone.0230489

Abstract

Surveillance of antimicrobial resistance (AMR) enables monitoring of trends in AMR prevalence. WHO recommends laboratory-based surveillance to obtain actionable AMR data at local or national level. However, laboratory-based surveillance may lead to overestimation of the prevalence of AMR due to bias. The objective of this study is to assess the difference in resistance prevalence between laboratory-based and population-based surveillance (PBS) among uropathogens in Indonesia. We included all urine samples submitted to the laboratory growing Escherichia coli and Klebsiella pneumoniae in the laboratory-based surveillance. Population-based surveillance data were collected in a cross-sectional survey of AMR in E. coli and K. pneumoniae isolated from urine samples among consecutive patients with symptoms of UTI, attending outpatient clinics and hospital wards. Data were collected between 1 April 2014 until 31 May 2015. The difference in percentage resistance (95% confidence intervals) between laboratory- and population-based surveillance was calculated for relevant antibiotics. A difference larger than +/- 5 percent points was defined as a biased result, precluding laboratory-based surveillance for guiding empirical treatment. We observed high prevalence of AMR ranging between 63.1% (piperacillin-tazobactam) and 85% (ceftriaxone) in laboratory-based surveillance and 41.3% (piperacillin-tazobactam) and 74.2% (ceftriaxone) in population-based surveillance, except for amikacin and meropenem (5.7%/9.8%; 10.8%/5.9%; [laboratory-/population-based surveillance], respectively). Laboratory-based surveillance yielded significantly higher AMR prevalence estimates than population-based surveillance. This difference was much larger when comparing surveillance data from outpatients than from inpatients. All point estimates of the difference between the two surveillance systems were larger than 5 percent points, except for amikacin and meropenem. Laboratory-based AMR surveillance of uropathogens, is not adequate to guide empirical treatment for community-based settings in Indonesia.

Highlights

Surveillance of antimicrobial resistance (AMR) enables monitoring of trends in AMR prevalence and is an important tool in the fight against the increasing threat of AMR globally
Laboratory-based surveillance with linkage to patient information is considered as the most efficient and feasible surveillance approach because the data are generated by microbiology laboratories that routinely identify and determine the susceptibility of bacteria isolated from clinical specimens submitted to the laboratory
The difference between laboratory-based surveillance estimates and population-based estimates was much larger for outpatients than for inpatients. These differences indicate that laboratory-based AMR prevalence data are not suitable to guide empirical treatment decisions, especially in the outpatient setting

Summary

Introduction

Surveillance of antimicrobial resistance (AMR) enables monitoring of trends in AMR prevalence and is an important tool in the fight against the increasing threat of AMR globally. Whilst laboratory-based surveillance can be used to provide information on local AMR prevalence with the aim to guide the empirical treatment choices, results of laboratory-based surveillance may be biased because of the potential barriers to and selection processes for submission of clinical specimens to laboratories for culture and susceptibility testing, in resource-constrained settings such as in LMIC [3,4]. This bias may result in laboratory-based surveillance results being skewed towards higher prevalence of AMR. Previous studies have assessed the potential sources of bias in laboratory-based surveillance, but studies that assess the actual difference in prevalence estimates between laboratorybased AMR surveillance and population-based surveillance in LMIC are lacking [5]

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Conclusion