A Clinically Oriented antimicrobial Resistance surveillance Network (ACORN): pilot implementation in three countries in Southeast Asia, 2019-2020

Abstract

Background: Case-based surveillance of antimicrobial resistance (AMR) provides more actionable data than isolate- or sample-based surveillance. We developed A Clinically Oriented antimicrobial Resistance surveillance Network (ACORN) as a lightweight but comprehensive platform, in which we combine clinical data collection with diagnostic stewardship, microbiological data collection and visualisation of the linked clinical-microbiology dataset. Data are compatible with WHO GLASS surveillance and can be stratified by syndrome and other metadata. Summary metrics can be visualised and fed back directly for clinical decision-making and to inform local treatment guidelines and national policy. Methods: An ACORN pilot was implemented in three hospitals in Southeast Asia (1 paediatric, 2 general) to collect clinical and microbiological data from patients with community- or hospital-acquired pneumonia, sepsis, or meningitis. The implementation package included tools to capture site and laboratory capacity information, guidelines on diagnostic stewardship, and a web-based data visualisation and analysis platform. Results: Between December 2019 and October 2020, 2294 patients were enrolled with 2464 discrete infection episodes (1786 community-acquired, 518 healthcare-associated and 160 hospital-acquired). Overall, 28-day mortality was 8.7%. Third generation cephalosporin resistance was identified in 54.2% (39/72) of E. coli and 38.7% (12/31) of K. pneumoniae isolates . Almost a quarter of S. aureus isolates were methicillin resistant (23.0%, 14/61). 290/2464 episodes could be linked to a pathogen, highlighting the level of enrolment required to achieve an acceptable volume of isolate data. However, the combination with clinical metadata allowed for more nuanced interpretation and immediate feedback of results. Conclusions: ACORN was technically feasible to implement and acceptable at site level. With minor changes from lessons learned during the pilot ACORN is now being scaled up and implemented in 15 hospitals in 9 low- and middle-income countries to generate sufficient case-based data to determine incidence, outcomes, and susceptibility of target pathogens among patients with infectious syndromes.

Keywords: Antimicrobial resistance; Case-based surveillance; Surveillance.

Figure 1.. Surveillance design and workflow.

CAI: community-acquired infection; HAI: hospital-acquired infection.

Figure 2.. Flowchart of enrolled patients, admissions, episodes and blood cultures.

Figure 3.. Hospital and post-discharge outcomes for 2408 patient admissions.

This plot includes all patient admissions. *Clinical diagnosis denotes first infection captured by surveillance per admission. †Post-discharge outcome denotes 28-day outcome when that time-point occurred following hospital discharge. Unknown post-discharge outcome status reflects either the 28-day outcome occurring before hospital discharge or inability to contact the patient following discharge.

Figure 4.. Potential pathogens isolated from 2123 blood cultures, by location and timing of infection onset.

CAI: community-acquired infection; HCAI: healthcare-associated infection; HAI: hospital-acquired infection.

Figure 5.

Antimicrobial susceptibility profiles for ( A) 61 Escherichia coli isolates and ( B) 54 Staphylococcus aureus isolates (all site data combined). The first isolate per specimen type for each patient was included. In each panel, the top plot summarises the infection category from which isolates were obtained, as a proportion (CAI, community-acquired; HCAI, healthcare-associated; HAI, hospital-acquired); the middle bar plot indicates the specimen (and thus isolate) count coloured by specimen type; and the bottom plot shows the antimicrobial susceptibility profile for the isolates (black filled circles indicate resistance and grey filled circles indicate susceptibility). The horizontal bars (“Set size”), indicate the number of isolates testing resistant a single antibiotic / antibiotic class (e.g., top row for S. aureus is penicillin and almost all isolates are resistant).