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Indian Journal of Medical Microbiology, Vol. 29, No. 3, July-September, 2011, pp. 205-206 Editorial Antimicrobial resistance: Action by laboratories today for a cure tomorrow R Kanungo Editor Indian Journal of Medical Microbiology A-3/No 38, Labourdonnaise Street, Puducherry - 605 001, India Date of Submission: 06-Jul-2011
Code Number: mb11053 PMID: 21860096 DOI: 10.4103/0255-0857.83899 Awareness of problems associated with antimicrobial resistance has spread beyond the medical fraternity to administrators and policy makers. Yet there is much to be done before any tangible impact is perceived. World Health Organization′s theme "No action today, no cure tomorrow" on Antimicrobial Resistance for World Health Day, this year, is testimony to growing concern of the problem. World Health Organization identifies several key areas contributing to increasing drug resistance. They are lack of commitment, weak or absent surveillance, poor drug quality, irrational drug use, no infection control, lack of research and development for drugs and diagnostics, and limited drugs and diagnostic arsenal [1] .There are two key points that are of particular relevance to the clinical microbiologists. These are (a) limited diagnostics and (b) lack of research into diagnostics. Quality of diagnostic tests: Correct and timely use of antibiotics, effective monitoring, and surveillance of resistance depend on quality of diagnostic tests. Improved diagnostic procedures should be an effective way to control infectious diseases and thereby spread of antibiotic resistance. To do so, tests should be reliable, timely, and cost-effective. Diagnostic tests and standards of practice vary in most clinical laboratories that perform antimicrobial susceptibility tests. Some laboratories perform standard tests, follow strict national/international guidelines, and adhere to quality control. A substantial number of laboratories both in public and private sector do not adhere to best practices, due to poor quality procedures. They are hampered by lack of awareness, funds, or skill. This is often compounded with nonavailability of quality material or having to compromise with substandard materials. Many laboratories fail to keep abreast of newer tools, changing guidelines, and test procedures. A concerted effort is required to bring all laboratories under the umbrella of quality practice to meet national standards. This can be best achieved through creating awareness and training in good clinical laboratory practice, to follow standard procedures, quality control, and quality assurance. Standard practice on antimicrobial testing must be strictly adhered to in the laboratory. Few basic tenets of antibiotic testing must include testing pure culture in the appropriate growth period, using potent antibiotic discs that have been quality checked, use of standard prescribed media, and incubation time. Results must be interpreted using international guidelines most notable being testing and interpretative criteria of Clinical Laboratory Standards Institute. Standard documentation of procedures and timely dissemination of results must be followed. It is to be remembered that an antibiotic resistance pattern must reach the treating clinician in the shortest possible time to avoid irrational use of antibiotics. Direct consultation between clinicians and laboratory personnel is necessary to improve laboratory′s response to patient care. In addition to the above measures within a laboratory, attempt must be made by concerned authorities to strengthen capacity of laboratories. Networking of laboratories within states and across the country will build the capacity of small and mid-level testing laboratories through technology transfer, training, and interlaboratory comparison of results. A tiered system of laboratories within small geographic areas with support from government or nongovernment bodies may be a viable mechanism to build the capacity of these laboratories. A model for external quality assurance for screening and diagnostic tests for HIV and CD4 testing has been established in public sector HIV testing laboratories, by the National AIDS Control Organization (NACO) [2] and for TB diagnosis by Revised National Tuberculosis Program (RNTCP). [3] A beginning has been made by the Indian Network for Surveillance for Antimicrobial Resistance supported by World Health Organization involving some public and private sector laboratories. This needs to be expanded to involve larger groups covering wider geographic area. Establishment of EQA in antibiotic susceptibility testing and continuing training programs could improve existing laboratory standards. A national antibiotic registry and reference mechanism is necessary to strengthen monitoring and surveillance of antimicrobial resistance and documenting emergence of novel resistant microorganisms in the country. Research in diagnostics for resistance detection: Research into understanding of basic mechanisms of resistance in microorganisms has led to the discovery of several techniques to detect these activities. While some are still in the nascent phase of laboratory-based in-house techniques, others have been standardized and more widely adopted. Pharmaceutical companies have cashed in on these innovations to market several rapid antimicrobial resistance detection methods. Nonmolecular methods based on conventional techniques such as the gradient technique to determine antibiotic, antifungal, and anti-tubercular drug susceptibility have been in the market for some time now and are widely available in India. Chromogenic screening media to detect Methicillin-Resistant Staphylococcus aureus, Vancomycin-Resistant Enterococcus, and Extended-Spectrum Beta Lactamase have come into the market. However, laboratories need to validate these with standard procedures before switching methods. It is imperative to maintain strict quality control using standard strains and reagents when using commercial tests. Expiry date, shelf life, and temperature for transport and storage have to be specifically monitored. Automated techniques for identification and determination of resistance phenotype are the latest addition to the diagnostic arsenal. High cost of equipment and recurring expenditure keep these out of reach of an average laboratory in the country. In recent years, molecular methods have been developed for not just detecting microorganisms but also the genes for antimicrobial resistance. These can be categorized into detecting the genes from clinical material, or from the isolate including, fastidious, and slow growing bacteria such as Neisseria gonorrhoeae, Helicobacter pylori, and Mycobacteria. Cost of the test is outweighed by the benefit achieved with rapid results. However, these techniques are beyond the reach of an average laboratory. To tackle current problem of rapidly increasing burden of MDR and XDR TB among the population, majority of who are poor, efforts are underway to make newer molecular diagnostic tools available through centralized testing facilities. This will be a boost to MDR/XDR TB diagnosis. Other methods for identifying major antibiotic resistance direct from specimen, culture free pathogens, and automated systems have been developed to give the results within a few hours. A word of caution at this stage would be prudent. Impact and sustainability of newer diagnostic techniques for patient care and their financial implications have to be evaluated before they can be recommended for use. In the absence of technologically advanced diagnostic tools, most laboratories in the country will have to rely on conventional techniques. To stem the tide of increasing antimicrobial resistance, testing laboratories have a crucial role to play. A beginning must be made by implementing good clinical laboratory practices. To highlight the growing concern for increasing antimicrobial resistance, this issue of Indian Journal of Medical Microbiology has focused on reviews, original research, and brief communications pertaining to antimicrobial resistance. References
Copyright 2011 - Indian Journal of Medical Microbiology |
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