Prevention Of Antimicrobial Resistance Research Articles

Antimicrobial resistance control efforts in Africa: a survey of the role of Civil Society Organisations

ABSTRACT Background: Antimicrobial resistance (AMR) is a growing public health threat in Africa. AMR prevention and control requires coordination across multiple sectors of government and civil society partners. Objectives: To assess the current role, needs, and capacities of CSOs working in AMR in Africa. Methods: We conducted an online survey of 35 CSOs working in 37 countries across Africa. The survey asked about priorities for AMR, current AMR-specific activities, monitoring practices, training needs, and preferences for sharing information on AMR. Further data were gathered on the main roles of the organisations, the length of time engaged in and budget spent on AMR-related activities, and their involvement in the development and implementation of National Action Plans (NAPs). Results were assessed against The Africa Centres for Disease Control and Prevention (Africa CDC) Framework for Antimicrobial Resistance (2018–2023). Results: CSOs with AMR-related activities are working in all four areas of Africa CDC’s Framework: improving surveillance, delaying emergence, limiting transmission, and mitigating harm from infections caused by AMR microorganisms. Engagement with the four objectives is mainly through advocacy, followed by accountability and service delivery. There were limited monitoring activities reported by CSOs, with only seven (20%) providing an example metric used to monitor their activities related to AMR, and 27 (80%) CSOs reporting having no AMR-related strategy. Half the CSOs reported engaging with the development and implementation of NAPs; however, only three CSOs are aligning their work with these national strategies. Conclusion: CSOs across Africa are supporting AMR prevention and control, however, there is potential for more engagement. Africa CDC and other government agencies should support the training of CSOs in strategies to control AMR. Tailored training programmes can build knowledge of AMR, capacity for monitoring processes, and facilitate further identification of CSOs’ contribution to the AMR Framework and alignment with NAPs and regional strategies.

Incidence and risk factors for hospital-acquired infection among paediatric patients in a teaching hospital: a prospective study in southeast Ethiopia

ObjectivesIn order to maximise the prevention of hospital-acquired infections (HAIs) and antimicrobial resistance, data on the incidence of HAIs are crucial. In Ethiopia, data about the occurrence of HAIs among...

A One Health Approach to Strengthening Antimicrobial Stewardship in Wakiso District, Uganda.

Antimicrobial stewardship (AMS), as one of the global strategies to promote responsible use of antimicrobials to prevent antimicrobial resistance (AMR), remains poor in many low-and middle-income countries (LMICs). We implemented a project aimed at strengthening AMS in Wakiso district, Uganda using a One Health approach. A total of 86 health practitioners (HPs), including animal health workers, and 227 community health workers (CHWs) participated in training workshops, and over 300 pupils from primary schools were sensitized on AMR, AMS, and infection prevention and control (IPC). We further established two multidisciplinary online communities of practice (CoPs) for health professionals and students, with a current membership of 321 and 162, respectively. In addition, a Medicine and Therapeutics Committee (MTC) was set up at Entebbe Regional Referral Hospital. The project evaluation, conducted three months after training, revealed that the majority of the HPs (92.2%) and CHWs (90.3%) reported enhanced practices, including improved hand washing (57.3% and 81.0%, respectively). In addition, 51.5% of the HPs reported a reduction in the quantity of unnecessary antibiotics given per patient. This project demonstrates that AMS interventions using a One Health approach can promote understanding of the prudent use of antimicrobials and improve practices at health facilities and in communities.

Implementation of an Antimicrobial Stewardship Program in Five Colombian Hospitals in 2018

Background: More than 50% of antibiotics used in hospitals are unnecessary or inappropriate. The antimicrobial stewardship programs (ASPs) are coordinated efforts to promote the rational and effective use of antibiotics including appropriate selection, dosage, administration, and duration of therapy. When an ASP integrates infection control strategies, it is possible to decrease the transmission of multidrug-resistant pathogens. Methods: In 2018, 5 Colombian hospitals were selected to implement an ASP. Private and public hospitals from different cities were included in the study, ranging from 200 to 700 beds. Our team, consisting of an infectious disease and hospital epidemiologist, visited each hospital to establish the baseline of their ASP program, to define the ASP outcomes according to each hospital’s needs, and to set goals for ASP outcomes in the following 6–12 months. Follow-up was scheduled every 2 months through Skype video conference. The baseline diagnosis or preintervention evaluation was done using a tool adapted from previous reports (ie, international consensus and The Joint Commission international standards). Documentation related to ASPs, such as microbiological profiles, antimicrobial guidelines (AMG) and indicators for the adherence to them as well as antimicrobial resistance (AMR) prevention through protocols, were written and/or updated. Prevention and infection control requirements and protocols were also updated, and cleaning and antiseptic policies were created. Training in rational use of antibiotic, infection control and prevention, and cleaning and disinfection were carried out with the healthcare workers in each institution. Results: Before the intervention, the development of the ASP according to the tool was 27% (range, 5%–47%). The lowest institutional scores were the item related to ASP feedback and reports (11% on average), followed by education and training (14%), defined ASP responsibilities (23%), ASP function according to priorities (26%), and AMR surveillance (27%). After the intervention, the ASP development increased to 57% (range, 39%–81%) in the hospitals. The highest scores achieved were for education and training (90%), surveillance (75%), and the activities of the infection control committee (70%). The items that made the greatest contribution to ASP development were the individual antibiogram, including the bacteria resistance profile, and the development of the AMG based on the local epidemiology in each hospital. Conclusions: The implementation of an ASP should include training and education as well as defining outcomes according to the hospital’s needs. Once the strategy is implemented, follow-up is key to achieving the goals.Funding: NoneDisclosures: None

Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis

Inappropriate antibiotics use and antimicrobial resistance (AMR) are increasingly becoming global health issues of great concern. Despite the established antibiotic stewardship programmes (ASPs) in many countries, limited efforts have been made to engage nurses and clearly define their roles in ASPs. An exploratory qualitative study was conducted to understand the facilitators and barriers that impact nurses' involvement and empowerment in antibiotic stewardship. Focus group discussions (FGDs) were conducted with purposively sampled nurses from three major public hospitals in Singapore. FGDs were audio-recorded and transcribed verbatim. Data were analysed using Applied Thematic Analysis and interpreted using the Social Ecological Model. At the intrapersonal level, nurses felt empowered in carrying out their roles in antibiotic administration. They saw themselves as gatekeepers to ensure that the prescribed antibiotics were administered appropriately. However, nurses felt they lacked the knowledge and expertise in antibiotic use and AMR prevention. At the interpersonal level, this deficit in knowledge and expertise in antibiotic use impacted how they were perceived by patients and caregivers as well as their interactions with the primary care team when voicing outpatient safety concerns and antibiotic administration suggestions. At the organizational level, nurses relied on drug administration guidelines to ensure appropriate antibiotic administration and as a safety net when physicians questioned their clinical practice. At the community level, nurses felt there was a lack of awareness and knowledge on antibiotic use among the general population. These findings provide important insights to harness the contributions of nurses, and to formally acknowledge and enlarge their roles in ASPs.

Evolutionary Approaches to Combat Antibiotic Resistance: Opportunities and Challenges for Precision Medicine.

The rise of antimicrobial resistance (AMR) in bacterial pathogens is acknowledged by the WHO as a major global health crisis. It is estimated that in 2050 annually up to 10 million people will die from infections with drug resistant pathogens if no efficient countermeasures are implemented. Evolution of pathogens lies at the core of this crisis, which enables rapid adaptation to the selective pressures imposed by antimicrobial usage in both medical treatment and agriculture, consequently promoting the spread of resistance genes or alleles in bacterial populations. Approaches developed in the field of Evolutionary Medicine attempt to exploit evolutionary insight into these adaptive processes, with the aim to improve diagnostics and the sustainability of antimicrobial therapy. Here, we review the concept of evolutionary trade-offs in the development of AMR as well as new therapeutic approaches and their impact on host-microbiome-pathogen interactions. We further discuss the possible translation of evolution-informed treatments into clinical practice, considering both the rapid cure of the individual patients and the prevention of AMR.

Finding the match between healthcare worker and expert for optimal audit and feedback on antimicrobial resistance prevention measures

BackgroundThe potentials of audit and feedback (AF) to improve healthcare are currently not exploited. To unlock the potentials of AF, this study focused on the process of making sense of audit data and translating data into actionable feedback by studying a specific AF-case: limiting antimicrobial resistance (AMR). This was done via audit and feedback of AMR prevention measures (APM) that are executed by healthcare workers (HCW) in their day-to-day contact with patients. This study’s aim was to counterbalance the current predominantly top-down, expert-driven audit and feedback approach for APM, with needs and expectations of HCW.MethodsQualitative semi-structured interviews were held with sixteen HCW (i.e. physicians, residents and nurses) from high-risk AMR departments at a regional hospital in The Netherlands. Deductive coding was succeeded by open and axial coding to establish main codes, subcodes and variations within codes.ResultsHCW demand insights from audits into all facets of APM in their working routines (i.e. diagnostics, treatment and infection control), preferably in the form of simple and actionable feedback that invites interdisciplinary discussions, so that substantiated actions for improvement can be implemented. AF should not be seen as an isolated ad-hoc intervention, but as a recurrent, long-term, and organic improvement strategy that balances the primary aims of HCW (i.e. improving quality and safety of care for individual patients and HCW) and AMR-experts (i.e. reducing the burden of AMR).ConclusionsTo unlock the learning and improvement potentials of audit and feedback, HCW’ and AMR-experts’ perspectives should be balanced throughout the whole AF-loop (incl. data collection, analysis, visualization, feedback and planning, implementing and monitoring actions). APM-AF should be flexible, so that both audit (incl. collecting and combining the right data in an efficient and transparent manner) and feedback (incl. persuasive and actionable feedback) can be tailored to the needs of various target groups. To balance HCW’ and AMR-experts’ perspectives a participatory holistic AF development approach is advocated.

A tribute to the foot soldiers: European health agencies in the fight against antimicrobial resistance.

The prevention of antimicrobial resistance (AMR) has been a flagship of the EU's health policy since the early 2000s, leading the European Commission to mandate three European agencies to cooperate in the fight against AMR: EMA (the European Medicines Agency), ECDC (European Centre for Disease Prevention and Control) and EFSA (the European Food Safety Agency). This article is at the intersection of EU health policy and the burgeoning scholarship on bureaucratic reputation. Little is known on the role played by reputational incentives on inter-agency cooperation. This empirical work supports the claim that cooperation creates incentives for agencies to protect their reputational uniqueness vis-à-vis each other. However, rather than threatening their cooperation, it amounts to a process of sense-making of their respective roles in the integrated fight against AMR. Evidence is generated through the agencies' textual sources, as well as in-depth interviews and analysed through a narrative analysis. From the early days of inter-agency cooperation, to recent legislative work, this paper offers in-depth insights on the EU's governance against AMR.

Feasibility and acceptance of a cloud-based mobile app for antimicrobial stewardship and infection control in Colombian hospitals.

Infection control and antimicrobial stewardship programs (ICASPs) are essential to reduce the emergence and spread of antimicrobial resistance. The primary objective of this study was to assess the feasibility of extending a commercial off-the-shelf (COTS) software for ICASPs in low- and middle-income countries (LMICs). This project involved three hospitals in Colombia, including Centro Médico Imbanaco, Clínica San Francisco, and DIME Clínica Neurocardiovascular. A COTS platform (ILÚM Health Solutions™ Kenilworth, NJ) was extended to function in a range of technology settings, and translatable to almost any language. ICASP features were added, including clinical practice guidelines, hand hygiene (HH) documentation, and isolation precaution (IP) documentation. The platform was delivered as a smartphone mobile application ("app") for both iOS and Android. The app was successfully implemented at all sites, however, full back-end data integration was not feasible at any site. In contrast to the United States, a suite of surveillance tools and physician-focused decision support without patient data proved to be valuable. Language translation processing occurred quickly and incurred minimal costs. HH and IP compliance tracking were the most used features among ICASP staff; treatment guidelines were most often used by physicians. Use of the app streamlined activities and reduced the time spent on ICASP tasks. Users consistently reported positive impressions including simplicity of design, ease of navigation, and improved efficiency. This ICASP app was feasible in limited-resource settings, highly acceptable to users, and represents an innovative approach to antimicrobial resistance prevention.

Implementing a combined infection prevention and control with antimicrobial stewardship joint program to prevent caesarean section surgical site infections and antimicrobial resistance: a Tanzanian tertiary hospital experience

BackgroundSurgical site infections are a leading cause of morbidity and mortality after caesarean section, especially in Low and Middle Income Countries. We hypothesized that a combined infection prevention and control with antimicrobial stewardship joint program would decrease the rate of post- caesarean section surgical site infections at the Obstetrics & Gynaecology Department of a Tanzanian tertiary hospital.MethodsThe intervention included: 1. formal and on-job trainings on infection prevention and control; 2. evidence-based education on antimicrobial resistance and good antimicrobial prescribing practice. A second survey was performed to determine the impact of the intervention. The primary outcome of the study was post-caesarean section surgical site infections prevalence and secondary outcome the determinant factors of surgical site infections before/after the intervention and overall. The microbiological characteristics and patterns of antimicrobial resistance were ascertained.ResultsTotal 464 and 573 women were surveyed before and after the intervention, respectively. After the intervention, the antibiotic prophylaxis was administered to a significantly higher number of patients (98% vs 2%, p < 0.001), caesarean sections were performed by more qualified operators (40% vs 28%, p = 0.001), with higher rates of Pfannenstiel skin incisions (29% vs 18%, p < 0.001) and of absorbable continuous intradermic sutures (30% vs 19%, p < 0.001). The total number of post-caesarean section surgical site infections was 225 (48%) in the pre-intervention and 95 (17%) in the post intervention group (p < 0.001). A low prevalence of gram-positive isolates and of methicillin-resistant Staphylococus aureus was detected in the post-intervention survey.ConclusionsFurther researches are needed to better understand the potential of a hospital-based multidisciplinary approach to surgical site infections and antimicrobial resistance prevention in resource-constrained settings.

Antibiotic consumption in developing countries defies global commitments: an overview on Brazilian growth in consumption.

Faster spread of epidemics has turned local concerns into global crises; antimicrobial resistance (AMR) is being considered a major threat to public health in the twenty-first century. Antibiotic misuse plays a great role in accelerated AMR; thus, understanding and discussing consumption patterns has been a trend topic over the past years. Developing countries, such as Brazil, have high growth rates in antibiotic consumption, potentially impacting global environmental safety. This study presents the compiled information from the Brazilian Health Regulatory Agency (ANVISA) on antibiotic dispensation across the country and maps the consumption trends between the years of 2013 and 2016. The most consumed substances were beta-lactams (amoxicillin and cephalexin) and macrolides (azithromycin). National relative growth consumption in the mentioned period was 18%. At the local level, growth of consumption ranged from 4 to 85%, with rampage growth concentrated in the North and Northeast regions. Brazilian laws, such as restriction of over-the-counter sales and mandatory report on dispensation, seem to have little effect on the national antibiotic consumption growth. This phenomenon growth is still elevated if compared with developed countries, demonstrating the need for further surveillance as well as coordinated efforts aiming at antibiotic use and AMR prevention.

Methodology and Early Results of the First Surveillance Program on Prevention and Control of Antimicrobial Resistance in Isfahan, Iran: The IAS-I Study.

Background:Isfahan Antibiotic Resistance Surveillance System-1 has been instituted in Isfahan, Iran to construct a project for surveillance of clinically significant bacteria, and to help raise a logic regional stewardship program for prevention and control of disseminating-resistant organisms.Methods:During March 2016 to March 2018, an antibiotic resistance surveillance system was designed and implemented by Isfahan Infectious Diseases and Tropical Medicine Research Center. The surveillance program was implemented in three general hospitals in Isfahan. In addition to the routine microbiology data, clinical data (differentiation between true infections and contamination, healthcare-associated infections (HCAI) and community-acquired infections (CAI), as well as determination of the infection site) were obtained and analyzed by WHONET software.Results:During a 2-year period, from 7056 samples that revealed growth of bacteria, 3632 (51.5%) isolates were detected as contamination and 3424 (48.5%) true bacterial isolates were identified. Of these, about 32% of isolates were recognized as HCAI. Totally, the most recognized infections were urinary tract infection, bloodstream infection and skin and soft tissue infections. In patients with HCAIs, 70% of isolates were gram negative and in patients with CAIs 73% isolates were gram negative bacteria.Conclusions:The strength of the project is gathering enough clinical information in addition to microbiologic data, which would increase application of the results for empiric treatment and prevention of the infectious diseases in clinical settings.

Development of New Antimicrobials for Urogenital Gonorrhea Therapy: Clinical Trial Design Considerations.

Gonorrhea remains a major public health challenge, and current recommendations for gonorrhea treatment are threatened by evolving antimicrobial resistance and a diminished pipeline for new antibiotics. Evaluations of potential new treatments for gonorrhea currently make limited use of new understanding of the pharmacokinetic and pharmacodynamic contributors to effective therapy, the prevention of antimicrobial resistance, and newer designs for clinical trials. They are hampered by the requirement to utilize combination ceftriaxone/azithromycin therapy as the comparator regimen in noninferiority trials designed to seek an indication for gonorrhea therapy. Evolving gonococcal epidemiology and clinical trial design constraints hinder the enrollment of those populations at the greatest risk for gonorrhea (adolescents, women, and persons infected with antibiotic-resistant Neisseria gonorrhoeae). This article summarizes a recent meeting on the evaluation process for antimicrobials for urogenital gonorrhea treatment and encourages the consideration of new designs for the evaluation of gonorrhea therapy.

Analysis of the modern approaches for the prevention of antimicrobial resistance: role and place of physical and chemical research methods in vitro and the investigation of bioequivalence

The problem of antimicrobial resistance is one of the key challenges in the modern world. A global analysis of the resistance development to antibacterial drugs has shown that solving this problem requires designing of complex interdisciplinary approaches. Searching for tools that would prevent and suppress the development of antimicrobial resistance is an actual scientific task that has a clear practical orientation. Aim. To analyze modern approaches, to avoid the development of antibacterial drugs resistance and to determine the role of physicochemical research IN VITRO and IN VIVO (bioequivalence studies) in solving this problem. Results. While carrying out the research, we made a systematic analysis of modern international concepts, regulatory guidelines, recommendations and programs for a comprehensive solution to the global problem of antibiotic resistance. During this work, we identified the key areas directly related to the issues of proper pharmaceutical development and research of antibacterial drugs, as well as the introduction of new scientific approaches and procedures for preventing the resistance of these drugs. It has been found that physicochemical methods of analysis can be used for scientifically substantiated creation of regimens of sustainable antibiotic therapy, as well as biopharmaceutical modeling of interaction with other objects (drugs, mineral waters, drinks, etc.). Such tests are an additional tool for excluding the risk of mismatch evaluation when conducting an assessment of generic drugs both in the biowaiver procedure and in the study of bioequivalence. Conclusions. The analysis of modern approaches to prevent the development of antibacterial drugs resistance has shown that it is necessary to use comprehensive application of scientific methods when making a research of this problem. The developed classification of approaches to eliminate antimicrobial resistance highlights the methods of physicochemical and bioanalytical research as a promising tool to reduce the risk of antibiotic resistance.

Cross-border comparison of antimicrobial resistance (AMR) and AMR prevention measures: the healthcare workers\u2019 perspective

BackgroundCross-border healthcare may promote the spread of multidrug-resistant microorganisms (MDRO) and is challenging due to heterogeneous antimicrobial resistance (AMR) prevention measures (APM). The aim of this article is to compare healthcare workers (HCW) from Germany (DE) and The Netherlands (NL) on how they perceive and experience AMR and APM, which is important for safe patient exchange and effective cross-border APM cooperation.MethodsA survey was conducted amongst HCW (n = 574) in hospitals in DE (n = 305) and NL (n = 269), using an online self-administered survey between June 2017 and July 2018. Mann-Whitney U tests were used to analyse differences between answers of German and Dutch physicians (n = 177) and German and Dutch nurses (n = 397) on 5-point Likert Items and Scales.ResultsSimilarities between DE and NL were a high awareness about the AMR problem and the perception that the possibility to cope with AMR is limited (30% respondents perceive their contribution to limit AMR as insufficient). Especially Dutch nurses scored significantly lower than German nurses on their contribution to limit AMR (means 2.6 vs. 3.1, p ≤ 0.001). German HCW were more optimistic about their potential role in coping with AMR (p ≤ 0.001), and scored higher on feeling sufficiently equipped to perform APM (p ≤ 0.003), although the mean scores did not differ much between German and Dutch respondents.ConclusionsAlthough both German and Dutch HCW are aware of the AMR problem, they should be more empowered to contribute to limiting AMR through APM (i.e. screening diagnostics, infection diagnosis, treatment and infection control) in their daily working routines. The observed differences reflect differences in local, national and cross-border structures, and differences in needs of HCW, that need to be considered for safe patient exchange and effective cross-border APM.

Antibiotic Consumption and Resistance during a 3-Year Period in Sicily, Southern Italy.

Antimicrobial resistance (AMR) is one of the biggest issues facing global public health. In 2017, Italy adopted its first National Action Plan on Antimicrobial Resistance 2017–2020, which works through the synergy between national, regional, and local levels. In the framework of a Regional Action Plan on healthcare-associated infections and AMR prevention, the Sicilian Health Authority of the Sicilian Region, Southern Italy, has implemented a surveillance system of antibiotic consumption in hospitals, in the community, and of resistance rates (RRs) in hospital settings. Data on antibiotic consumption and on antibiotic RRs have been collected from 2015 to 2017 from pharmacies and laboratories of participating hospitals and from community, respectively. Data on antibiotic consumption showed that the most consumed antibiotics in hospitals were fluoroquinolones in 2015, penicillin in 2016, and beta-lactams in 2017. From 2015 to 2017, data on Klebsiella pneumoniae showed significant increasing RRs to all antibiotic classes, except to carbapenems. RRs of third-generation cephalosporins and carbapenems Escherichia coli showed significant decreasing trends. RRs of the other microorganisms did not change significantly during the study period. The results from the present study show that in Sicily, the use of antibiotics and RRs for selected microorganisms are at a high level. Immediate strategies are needed to decrease the inappropriate usage of antibiotics and control the spread of AMR.

Implementation research for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva infection prevention and control (IPC)-think tank (part 1)

BackgroundAround 5–15% of all hospital patients worldwide suffer from healthcare-associated infections (HAIs), and years of excessive antimicrobial use in human and animal medicine have created emerging antimicrobial resistance (AMR). A considerable amount of evidence-based measures have been published to address these challenges, but the largest challenge seems to be their implementation.MethodsIn June 2017, a total of 42 experts convened at the Geneva IPC-Think Tank to discuss four domains in implementation science: 1) teaching implementation skills; 2) fostering implementation of IPC and antimicrobial stewardship (AMS) by policy making; 3) national/international actions to foster implementation skills; and 4) translational research bridging social sciences and clinical research in infection prevention and control (IPC) and AMR.ResultsAlthough neglected in the past, implementation skills have become a priority in IPC and AMS. They should now be part of any curriculum in health care, and IPC career paths should be created. Guidelines and policies should be aligned with each other and evidence-based, each document providing a section on implementing elements of IPC and AMS in patient care. International organisations should be advocates for IPC and AMS, framing them as patient safety issues and emphasizing the importance of implementation skills. Healthcare authorities at the national level should adopt a similar approach and provide legal frameworks, guidelines, and resources to allow better implementation of patient safety measures in IPC and AMS. Rather than repeating effectiveness studies in every setting, we should invest in methods to improve the implementation of evidence-based measures in different healthcare contexts. For this, we need to encourage and financially support collaborations between social sciences and clinical IPC research.ConclusionsExperts of the 2017 Geneva Think Tank on IPC and AMS, CDC, and WHO agreed that sustained efforts on implementation of IPC and AMS strategies are required at international, country, and hospital management levels, to provide an adequate multimodal framework that addresses (not exclusively) leadership, resources, education and training for implementing IPC and AMS. Future strategies can build on this agreement to make strategies on IPC and AMS more effective.

Technology for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva IPC-Think Tank (Part 2)

BackgroundThe high burden of healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) is partially due to excessive antimicrobial use both in human and animal medicine worldwide. How can technology help to overcome challenges in infection prevention and control (IPC) and to prevent HAI and emerging AMR?MethodsIn June 2017, 42 international experts convened in Geneva, Switzerland to discuss four potential domains of technology in IPC and AMR: 1) role and potential contribution of microbiome research; 2) whole genome sequencing; 3) effectiveness and benefit of antimicrobial environmental surfaces; and 4) future research in hand hygiene.ResultsResearch on the microbiome could expand understanding of antimicrobial use and also the role of probiotics or even faecal transplantation for therapeutic purposes. Whole genome sequencing will provide new insights in modes of transmission of infectious diseases. Although it is a powerful tool for public health epidemiology, some challenges with interpretation and costs still need to be addressed. The effectiveness and cost-effectiveness of antimicrobially coated or treated environmental high-touch surfaces requires further research before they can be recommended for routine use. Hand hygiene implementation can be advanced, where technological enhancement of surveillance, technique and compliance are coupled with reminders for healthcare professionals.ConclusionsThe four domains of technological innovation contribute to the prevention of HAI and AMR at different levels. Microbiome research may offer innovative concepts for future prevention, whole genome sequencing could detect new modes of transmission and become an additional tool for effective public health epidemiology, antimicrobial surfaces might help to decrease the environment as source of transmission but continue to raise more questions than answers, and technological innovation may have a role in improving surveillance approaches and supporting best practice in hand hygiene.

Infection prevention: laying an essential foundation for quality universal health coverage

Infection prevention: laying an essential foundation for quality universal health coverage

Expanding beyond zoonoses: the benefits of a national One Health coordination mechanism to address antimicrobial resistance and other shared health threats at the human-animal-environment interface in Kenya.

In order to manage global and transnational health threats at the human- animal-environment interface, a multisectoral One Health approach is required. Threats of this nature that require a One Health approach include, but are not limited to, emerging, endemic and re-emerging zoonotic diseases, food safety, antimicrobial resistance (AMR), vector-borne and neglected infectious diseases, toxicosis and pesticides. Relevant Kenyan authorities formally institutionalised One Health in 2011 through the establishment of the Zoonotic Disease Unit (ZDU) and its advisory group, the Zoonoses Technical Group. At that time, the One Health agenda focused on zoonotic diseases. As the issue of AMR began to gain traction globally, a One Health approach to its management was advocated in Kenya in 2015. This paper summarises a series of interviews (with respondents and key informants) that describe how AMR institutionalisation evolved in Kenya. It also examines how responses to other health threats at the human-animal- environment interface were coordinated and used to identify gaps and make recommendations to improve One Health coordination at the national level in Kenya. Results showed that the road to the institutionalisation of AMR through the National Action Plan on Prevention and Containment of Antimicrobial Resistance, 2017-2022 and a formally launched One Health coordination mechanism, the National Antimicrobial Stewardship Interagency Committee (NASIC), took ten years. Moreover, supplementary actions are still needed to further strengthen AMR coordination. In addition to the ZDU and NASIC, Kenya has established two other formal multisectoral and multidisciplinary coordination structures, one for aflatoxicosis and the other for health threats associated with pesticide use. The country has four distinct and separate One Health coordination mechanisms: for zoonoses, for AMR, for aflatoxicosis and for the health threats associated with pesticide use. The main gap lies in the lack of overall coordination between these topic-specific structures. An overall coordination mechanism for all One Health issues is therefore needed to improve synergy and complementarity. None of the topic-specific mechanisms plays a critical role in the policy development process, institutionalisation or implementation of activities related to the other topic areas. The authors recommend renaming the ZDU as the One Health Office, and expanding it to include AMR and food safety teams, and their associated technical working groups. Through this restructuring, the One Health Office would become an umbrella organisation dealing with all four issues mentioned above. Based on Kenya's experience, the authors recommend that other countries also consider expanding the scope of multisectoral One Health coordination mechanisms to include other shared health threats.