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      ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network): a pilot protocol for case based antimicrobial resistance surveillance

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          Abstract

          Background: Antimicrobial resistance (AMR) / drug resistant infections (DRIs) are a major global health priority. Surveillance data is critical to inform infection treatment guidelines, monitor trends, and to assess interventions. However, most existing AMR / DRI surveillance systems are passive and pathogen-based with many potential biases. Addition of clinical and patient outcome data would provide considerable added value to pathogen-based surveillance.

          Methods: The aim of the ACORN project is to develop an efficient clinically-oriented AMR surveillance system, implemented alongside routine clinical care in hospitals in low- and middle-income country settings. In an initial pilot phase, clinical and microbiology data will be collected from patients presenting with clinically suspected meningitis, pneumonia, or sepsis. Community-acquired infections will be identified by daily review of new admissions, and hospital-acquired infections will be enrolled during weekly point prevalence surveys, on surveillance wards. Clinical variables will be collected at enrolment, hospital discharge, and at day 28 post-enrolment using an electronic questionnaire on a mobile device. These data will be merged with laboratory data onsite using a flexible automated computer script. Specific target pathogens will be Streptococcus pneumoniae, Staphylococcus aureus, Salmonella spp ., Klebsiella pneumoniae, Escherichia coli, and Acinetobacter baumannii. A bespoke browser-based app will provide sites with fully interactive data visualisation, analysis, and reporting tools.

          Discussion: ACORN will generate data on the burden of DRI which can be used to inform local treatment guidelines / national policy and serve as indicators to measure the impact of interventions. Following development, testing and iteration of the surveillance tools during an initial six-month pilot phase, a wider rollout is planned.

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          Most cited references19

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          Measuring and mapping the global burden of antimicrobial resistance

          The increasing number and global distribution of pathogens resistant to antimicrobial drugs is potentially one of the greatest threats to global health, leading to health crises arising from infections that were once easy to treat. Infections resistant to antimicrobial treatment frequently result in longer hospital stays, higher medical costs, and increased mortality. Despite the long-standing recognition of antimicrobial resistance (AMR) across many settings, there is surprisingly poor information about its geographical distribution over time and trends in its population prevalence and incidence. This makes reliable assessments of the health burden attributable to AMR difficult, weakening the evidence base to drive forward research and policy agendas to combat AMR. The inclusion of mortality and morbidity data related to drug-resistant infections into the annual Global Burden of Disease Study should help fill this policy void.
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            Antimicrobial Resistance in Invasive Bacterial Infections in Hospitalized Children, Cambodia, 2007–2016

            To determine trends, mortality rates, and costs of antimicrobial resistance in invasive bacterial infections in hospitalized children, we analyzed data from Angkor Hospital for Children, Siem Reap, Cambodia, for 2007–2016. A total of 39,050 cultures yielded 1,341 target pathogens. Resistance rates were high; 82% each of Escherichia coli and Klebsiella pneumoniae isolates were multidrug resistant. Hospital-acquired isolates were more often resistant than community-acquired isolates; resistance trends over time were heterogeneous. K. pneumoniae isolates from neonates were more likely than those from nonneonates to be resistant to ampicillin–gentamicin and third-generation cephalosporins. In patients with community-acquired gram-negative bacteremia, third-generation cephalosporin resistance was associated with increased mortality rates, increased intensive care unit admissions, and 2.26-fold increased healthcare costs among survivors. High antimicrobial resistance in this setting is a threat to human life and the economy. In similar low-resource settings, our methods could be reproduced as a robust surveillance model for antimicrobial resistance.
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              Surveillance for antimicrobial resistant organisms: potential sources and magnitude of bias.

              Surveillance has been recognized as a fundamental component in the control of antimicrobial- resistant infections. Although surveillance data have been widely published and utilized by researchers and decision makers, little attention has been paid to assessment of their validity. We conducted this review in order to identify and explore potential types and magnitude of bias that may influence the validity or interpretation of surveillance data. Six main potential areas were assessed. These included bias related to use of inadequate or inappropriate (1) denominator data, (2) case definitions, and (3) case ascertainment; (4) sampling bias; (5) failure to deal with multiple occurrences, and (6) those related to laboratory practice and procedures. The magnitude of these biases varied considerably for the above areas within different study populations. There are a number of potential biases that should be considered in the methodological design and interpretation of antimicrobial-resistant organism surveillance.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Funding AcquisitionRole: MethodologyRole: Project AdministrationRole: SoftwareRole: VisualizationRole: Writing – Original Draft Preparation
                Role: MethodologyRole: Writing – Review & Editing
                Role: SoftwareRole: VisualizationRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: MethodologyRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: MethodologyRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: InvestigationRole: Writing – Review & Editing
                Role: Data CurationRole: SoftwareRole: Writing – Review & Editing
                Role: Data CurationRole: SoftwareRole: Writing – Review & Editing
                Role: ConceptualizationRole: MethodologyRole: Project AdministrationRole: Writing – Review & Editing
                Journal
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Research
                F1000 Research Limited (London, UK )
                2398-502X
                27 January 2020
                2020
                : 5
                : 13
                Affiliations
                [1 ]Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
                [2 ]Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
                [3 ]Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
                [4 ]Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
                [5 ]Eijkman-Oxford Clinical Research Unit, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
                [6 ]Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
                [7 ]National Hospital for Tropical Diseases, Hanoi, Vietnam
                [8 ]Oxford University Clinical Research Unit, National Hospital for Tropical Diseases, Hanoi, Vietnam
                [1 ]Division of Medical Microbiology, Faculty of Medicine and Health Sciences, NHLS, Tygerberg Hospital, Stellenbosch University, Tygerberg, South Africa
                [1 ]Department of Medical Microbiology, University of Ghana, Accra, Ghana
                [1 ]Tufts University, Medford, MA, USA
                [1 ]Liverpool School of Tropical Medicine, Liverpool, UK
                Centre for Tropical Medicine, University of Oxford, UK
                Author notes

                No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Competing interests: None that I can think of.

                Author information
                https://orcid.org/0000-0002-1013-7815
                https://orcid.org/0000-0002-7620-4822
                https://orcid.org/0000-0002-2971-9110
                https://orcid.org/0000-0002-5007-7896
                https://orcid.org/0000-0002-0237-1070
                https://orcid.org/0000-0002-9807-1821
                Article
                10.12688/wellcomeopenres.15681.1
                7250055
                32509968
                db6cf67b-c710-4de9-bafc-7650841c67fb
                Copyright: © 2020 Turner P et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 22 January 2020
                Funding
                Funded by: Wellcome Trust
                Award ID: 215867
                This work was supported by the Wellcome Trust [215867; to PT].
                Categories
                Study Protocol
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