(2)AMR Presentation on 29-30 Decemer Pheak 281222 2.pptx
1. Report of AMR Surveillance Data Analysis:
Jan to Oct 2020
Presenter: Dr. Veng Mom, NPHL/NIPH
29-30 Dec 2022
Vimean Neak Thmey, Kampong Chhang
AMR Surveillance Workshop
2. Table of contents
I. Background
II. Objectives
III. Methods
IV. Results
V. Remarkable findings
VI. Strength
VII.Challenges
VIII.Way forward
IX. Bibliographies
AMR
Surveillance
Data
3. AMR
Surveillance
Data I. Background: AMR Surveillance System
• Antimicrobial resistance (AMR) represents a major threat to human health with
significant global economic and security implications .
• There were an estimated 4·95 million deaths associated with bacterial AMR in 2019.
• Lower respiratory infections accounted for more than 1·5 million deaths associated
with resistance in 2019.
• The six leading pathogens for deaths associated with resistance (E.coli, S. aureus, K.
pneumoniae, Strep.pneumoniae, Acinetobacter, and P. aeruginosa) were responsible
for 929 000 deaths attributable to AMR and 3·57 million deaths associated with AMR
in 2019.
Surveillance is an essential tool to monitor the spread of AMR in order to urgently
inform policies for infection prevention and control response.
4. AMR
Surveillance
Data
II. Objectives
• Determine confirmation result for identification and AST between reference lab
and sentinel sites
• Identify bacteria producing ESBL and MRSA
• Determine strength, challenges, and further actions to improve the implementation
of AMR surveillance.
6. Sample Characteristics and Sources
• Sample type: Blood & CSF culture
• Target organism from blood:
o E.coli, K.pneumoniae, S.aureus, S.pneumoniae, Acinetobacter, Salmonella,
and B.pseudomallei (B.pseudomallei is not sent to NPHL for confirmation)
• Target organism from CSF:
o All true pathogens
• Five labs (SR, BB, KC, TK and NPH) send isolates to NIPH for ID & AST
confirmation.
• Three labs (Calmette, AHC, SHCH) send only data to NPHL.
AMR
Surveillance
Data
7. • For ID
o Biochemical reagents + commercial ID system API (Biomerieux)
• For AST
o CLSI M02 for disk diffusion method
o Etest manufacturers instructions
o CLSI M100 28-29ed for interpretation and IQC
Confirmation testing procedure
AMR
Surveillance
Data
8. • IQC
o AST IQC perform weekly
o Use ATCC E.coli 25922, E.coli 35218, S.aureus 25923, P.aeruginosa 27853,
S.pneumoniae 49619
o Follow IQC breakpoints from CLSI M100
o Media from Central Media Making Laboratory with certificate of analysis
• EQA
o EQA received 3 times per year with 100% participation from PPTC, New Zealand
o EQA received 4 times per year with 100% participation from RCPAQAP, Australia
AST
• Staff competency perform yearly
Quality Assurance
AMR
Surveillance
Data
9. Pathogen identification NPHL Identification
Score
NPHLAST
Score
2020/1
Staphylococcus lugdunensis 3/3 5/5
Salmonella typhimurium 3/3 Not required
2020/2
Pasteurella multocida 2/2 Not Required
Streptococcus pneumoniae 2/2 7/8
Staphylcoccuc saprophyticus 2/2 3/3
2020/3
Staphylcoccuc aureus 2/2 5/5
K.pneumoniae 2/2 10/10
Candida albican 2/2 Not required
EQA, PPTC, 2020
GLASS priority pathogens
included in PPTC:
Klebsiella pneumoniae
S.aureus
Strep.pnumae
Salmonella typhimurium………
9
AMR
Surveillance
Data
10. EQA, RCPAQAP, 2020, supported by DMDP
• Started enrollment since 2020
• Received sample 4 times per year
• Samples: difficult blood culture isolate, faecal, genital swab, respiratory
pathogen, nose/throat, urine and Gram stain microscopy
• Very challenges but gain more improvement
• Assessment result: Concordance and Discordant
AMR
Surveillance
Data
NPHL
NPHL
Provider
Provider
11. CLSI best practices for evaluation of AST
• Discrepancies can be observed even under ideal conditions
NPHL initiated regular Zoom meeting-problem
solving, Corrective Action, Preventive Action
Resolving
discrepancy
Systematic
review
1 Check
Isolate
Correct
lab/isolate
number
Pure culture
2 Check
Worksheets
Transcription
errors
Interpretation
errors
3 Check QA
Materials-
Media
Reagents, Discs
SOP
IQC
Personnel
competency
4 Repeat
testing
NPHL
Both sites
AMR
Surveillance
Data
13. Isolate Received from Five Sentinel Sites: Jan-Oct 2020
Specimen type BB KC NPH SR TK Total
Blood culture 43 39 161 86 95 424
LCR/CSF 0 2 1 2 2 7
Sample rejection 2 1 31 0 3 37
Total 45 42 193 88 100 468
AMR
Surveillance
Data
14. Confirmation Results by Site: Jan-Oct 2020
AMR
Surveillance
Data
Confirmation Test Kampong Cham Takeo Siem Reap Battambang
# % # % # % # %
Identification 39 100 97 100 87 100 43 100
AST by Disc test 397 99.5 888 96.9 876 97.8 450 98.4
AST Discrepancy 2 0.5 27 3.1 19 2.2 7 1.2
Note: %: percentage of agreement confirmation result between NPHL and Sentinel Sites
15. Confirmation Results by Bacteria: Jan-Oct 2020
AMR
Surveillance
Data
Confirmation test E.coli S.aureus K.pneumoniae Acinetobacter Salmonella Strep.pneumoniae
# % # % # % # % # % # %
Identification 93 100 46 100 16 100 38 100 43 100 7 100
AST by disc test 1116 97.7 405 100 516 98.8 270 100 301 100 77 90.9
AST discrepancy 21 1.9 10 2.5 12 2.3 0 0 0 0 5 6.5
Note:
%: percentage of agreement confirmation result between NPHL and Sentinel Sites
Note: Isolates of Streptococcus suis, S.paratyphi A, and Salmonella typhi were not received for confirmation
16. AMR
Surveillance
Data
AST Confirmation Result by Bacteria for BBT: Jan-Oct 2020
97.7
100
98.8
100
100
90.9
0 20 40 60 80 100
E.coli
S.aureus
K.pneumoniae
Acinetobacter
Salmonella
S.pneumoniae
% of agreement confirmation result
17. AMR
Surveillance
Data
AST Confirmation Result by Bacteria for Kg Cham: Jan-Oct 2020
100
98.4
98.9
100
100
100
90.9
0 20 40 60 80 100
E.coli
S.aureus
K.pneumoniae
Acinetobacter
Salmonella
Salmonella typhi
S.pneumoniae
% of agreement confirmation result
18. AMR
Surveillance
Data
AST Confirmation Result by Bacteria for Takeo: Jan-Oct 2020
97.1
93.5
97.9
85.2
100
100
100
100
100
0 20 40 60 80 100
E.coli
S.aureus
K.pneumoniae
Acinetobacter
Salmonella
S.paratyphi A
Salmonella typhi
S.pneumoniae
S.suis
% of agreement confirmation result
19. AMR
Surveillance
Data
AST Confirmation Result by Bacteria for Siem Reap: Jan-Oct 2020
Note: Isolates of Streptococcus suis and Salmonella typhi were not received for confirmation
98.3
98.4
96.4
100
100
100
86.4
0 20 40 60 80 100
E.coli
S.aureus
K.pneumoniae
Acinetobacter
Salmonella
S.paratypi A
S.pneumoniae
% of agreement confirmation result
20. Bacteria Produced ESBL and MRSA
AMR
Surveillance
Data
Bacteria total ESBL detected by
Combination disc
MRSA detected by
Cefoxitin disc
# % # %
E.coli 91 77 84.6 - -
K.pneumoniae 43 32 74.4 - -
S.aureus 45 - - 15` 33.3
Confirmation Results was 100%
21. AMR
Surveillance
Data
V. Remarkable Findings from the Analysis: Jan-Oct 2020
• Identification confirmation result was 100 percent correct across all sites.
• AST discrepancy results were identified from all sentinel sites referred isolate to
NPHL and particularly found among S.pneumoniae, K.pneumoniae, and E.coli.
• E.coli and K.pneumoniae produced ESBL while S.aureus detected MRSA.
22. VI. Strength related to AMR surveillance implementation
• Experienced from each participant on:
- IQC M02 & M100, AST performance, Trouble shooting, ATCC maintenance, How to
access online to CLSI M100, Antibiotic disc storage.
• Enrolled EQA from RCPAQAP, Australia
• Strengthened ATCC strain maintenance and completed staff competency assessment
• Participated updating AST guideline 2020
• Continued education via weekly zoom training with DMDP and received certification
• Strengthened operation of Vitek-MS and Vitek 2 compact machine and completed staff
competency assessment
AMR
Surveillance
Data
23. VII. Challenges
• Sentinel site staff have prioritized to work for COVID-19 response
• Isolate wasn’t sent to reference lab according to schedule
• Late feedback results to sentinel sites (sometimes > 2 weeks)
• Not enough staff in NPHL Microbiology lab to assist AMR.
• AMR database management was not well managed
• Insufficient funding
AMR
Surveillance
Data
24. VIII. Way forward
• Appoint AMR staff at sentinel site to regularly perform AMR tasks.
• Set up google calendar to notify sending isolate
• Appoint NPHL microbiology staff to verify and feedback result to sentinel sites
• Set up alert system for turn around time of AMR result
• Make a realistic schedule between reference lab and sentinel sites for solving
discrepancy result
• Upgrade NPHL AMR database to meet with AMR reporting standard
• Seek available fund for supporting more staff and supplies for AMR
performance
AMR
Surveillance
Data
25. AMR
Surveillance
Data
IX. Bibliographies
• WHO. World Health Organization. Global Antimicrobial Resistance and Use
Surveillance System (GLASS). https://www.who.int/initiatives/glass.
• Cristopher JL. et all. Global burden of bacterial antimicrobial resistance in 2019: a
systematic analysis. Lancet, 399:629.
