Antimicrobial Resistance (AMR)

  • .Allegranzi B, Pittet D. (2007). Healthcare-Associated Infection in Developing Countries: Simple Solutions to Meet Complex Challenges. Infection Control & Hospital Epidemiology, 28(12), 1323-27.
    • Health-care associated infections are usually linked to sophisticated medical technology and the use of invasive devices. However, a more complex range of factors determines the risk of acquiring an infection in a healthcare setting in developing countries. The inappropriate use of antibiotics and the use of counterfeit drugs contribute to a high rate of antimicrobial resistance, although this is poorly documented because of the lack of reliable surveillance systems.
  • Armed Forces Health Surveillance Center, US Department of Defense. (2010). The Armed Forces Health Surveillance Center: Global Emerging Infections Surveillance & Response System. Silver Spring: Armed Forces Health Surveillance Center.
    • The Armed Forces Health Surveillance Center (AFHSC) was created to centralize Department of Defense (DoD) domestic and international healthcare surveillance efforts. The organization provides relevant, timely, actionable, and comprehensive health information and supports the military and military-associated populations. The Global Emerging Infections Surveillance and Response System (GEIS) at AFHSC promotes national and international preparedness for emerging infections while maintaining its focus on protecting the health of all DoD health care beneficiaries. The surveillance programs of GEIS focus on five categories of infectious diseases, including antimicrobial resistance. 
  • Ashiru-Oredope D, Cookson B, Fry C, et al. (2014). Developing the first national antimicrobial prescribing and stewardship competencies. Journal of Antimicrobial Chemotherapy, 69(11), 2886-88.
    • Antimicrobial resistance is a national and worldwide threat to the future of healthcare. Educating both healthcare staff and the public in the prudent use of antimicrobials is an essential part of antimicrobial stewardship programmes that aim to contain and control resistance and preserve the usefulness of currently available antibiotics. Using available evidence, regulatory documents and national antimicrobial stewardship guidance for primary and secondary care, England has developed five dimensions for antimicrobial prescribing and stewardship competences through an independent multi-professional group. They are designed to complement the generic competency framework for all prescribers from the UK National Prescribing Centre and are relevant to independent prescribers, including doctors, dentists, and non-medical practitioners. The published competencies are believed to be the first of their kind and their Implementation will be an important contribution to the delivery of the UK government’s 5-year Antimicrobial Resistance Strategy.
  • Bedenkov A, Shpinev V, Suvorov N, et al. (2016). Consolidating Russia and Eurasia Antibiotic Resistance Data for 1992–2014. Frontiers in Microbiology, 7, 294-300.
    • The World Health Organization recognizes the antibiotic resistance problem as a major health threat in the twenty-first century. The paper describes an effort to fight it undertaken at the verge of two industries: healthcare and data science. One of the major difficulties in monitoring antibiotic resistance is the low-availability of comprehensive research data The researchers developed a nation-wide antibiotic resistance database using Internet search and data processing algorithms – providing a supplementary tool to national surveillance systems in antibiotic resistance and consolidates fragmented research data. 
  • Bronzwaer SL, Cars O, Buchholz U, et al. (2002). The Relationship between Antimicrobial Use and Antimicrobial Resistance in Europe. Emerging Infectious Diseases, 8(3), 278-82.
    • In Europe, antimicrobial resistance has been monitored since 1998 by the European Antimicrobial Resistance Surveillance System (EARSS). This article examines the relationship between penicillin nonsusceptibility of invasive isolates of Streptococcus pneumoniae (an indicator organism) and antibiotic sales. Information was collected on 1998-99 resistance data for invasive isolates of S. pneumoniae to penicillin, based on surveillance data from EARSS and on outpatient sales during 1997 for beta-lactam antibiotics and macrolides. Results show that in Europe antimicrobial resistance is correlated with use of beta-lactam antibiotics and macrolides.
  • Burnham CAD, Leeds J, Nordmann P, et al. (2017). Diagnosing antimicrobial resistance. Nature Reviews Microbiology, 15(11), 697-703.
    • Antimicrobial resistance constitutes a global burden and is a major threat to public health. Although the emergence of resistant microorganisms is a natural phenomenon, the overuse or inappropriate use of antimicrobials has had a great effect on resistance evolution. Rapid diagnostic tests that identify drug-resistant bacteria, determine antimicrobial susceptibility and distinguish viral from bacterial infections can guide effective treatment strategies. Moreover, rapid diagnostic tests could facilitate epidemiological surveillance, as emerging resistant infectious agents and transmission can be monitored. This viewpoint article discusses the drawbacks of current diagnostic methods that are used to identify antimicrobial resistance, novel diagnostic strategies and how such rapid tests can inform drug development and the surveillance of resistance evolution.
  • Cailes B, Vergnano S, Kortsalioudakia C, et al. (2015). The current and future roles of neonatal infection surveillance programmes in combating antimicrobial resistance. Early Human Development, 91(11), 613-18.
    • Neonatal sepsis is an important cause of morbidity and mortality, particularly in premature or low birth weight babies. Hospital-acquired bloodstream infections represent a significant and largely preventable cause of disease in this population. Neonatal units have been identified as a common site for the development and transmission of antimicrobial-resistant pathogens, a significant issue in modern medicine. Neonatal surveillance programmes collect prospective data on infection rates and may be used to optimize therapy, benchmark practice and develop quality improvement programmes. Despite this, the number of networks is relatively few and these are largely concentrated in resource-rich nations. Furthermore, surveillance definitions may vary between programmes impairing our ability to draw comparisons between them. Better harmonization is required between networks to ensure that they achieve their potential as a valuable tool for benchmarking of hospital-acquired infection rates between units. 
  • Carlet J, Pulcini C, Piddock LJV. (2014). Antibiotic resistance: a geopolitical issue. Clinical Microbiology and Infection, 20(10), 949-53.
    • Antimicrobial resistance (AMR), associated with a lack of new antibiotics, is a major threat. Some countries have been able to contain resistance, but in most countries, the numbers of antibiotic-resistant bacteria continue to increase, along with antibiotic consumption by humans and animals. Some initiatives have been undertaken in the last 15 years, but those initiatives were partial and poorly implemented, without coordination. Some important initiatives have recently been implemented by the WHO and international task forces. At a national level, some important initiatives have been implemented, in particular in European countries and in the US. The Chennai Declaration, in India, is also a good example of a highly political, multidisciplinary, and national initiative. Finally, several non-governmental non-profit organizations are also active and have helped to raise awareness about the problem of AMR. Future work will require political involvement and strong multilateral cooperation. 
  • Carlet J, Astagneau P, Brun-Buisson C, et al. (2009). French National Program for Prevention of Healthcare-Associated Infections and Antimicrobial Resistance, 1992–2008: Positive Trends, But Perseverance Needed. Infection Control & Hospital Epidemiology, 30(8), 737-45. 
    • A comprehensive national program has gradually been set up in France during the period from 1993 to 2004, which included strengthening of organized infection control activities at the local, regional, and national levels and developing large networks for surveillance of specific infections and antibiotic resistance. This report describes the French program for the prevention of healthcare-associated infections and antibiotic resistance and provides results for several indicators available to evaluate the program. Although continued efforts are required, the program appears to have been effective at reducing infection rates.
  • Cornaglia G, Hryniewicz W, Jarlier V, et al. (2004). European recommendations for antimicrobial resistance surveillance. Clinical Microbiology and Infection, 10(4), 349-83.
    • The problem of antimicrobial resistance (AMR) surveillance in Europe has been debated extensively. This document presents recommendations that focus on the detection of bacterial resistance and its reporting to a wide, ever-increasing audience. The basis for AMR monitoring is microbiological diagnostics, which require adequate data that have been properly recorded and evaluated. Different types of surveillance studies should fulfill different requirements with regard to data collection and reporting, the expected use of data, and the prerequisites for networking such activities. To generate relevant indicators, bacterial resistance data should be reported using appropriate denominators and stratification. Reporting of AMR data is necessary for selection of empirical therapy at the local level, for assessing the scale of the resistance problem at the local, national or international levels, for monitoring changes in resistance rates, and for detecting the emergence and spread of new resistances types. 
  • Davey P, Sneddon J, Nathwani D. (2010). Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Review of Clinical Pharmacology, 3(5), 667-86.
    • The discovery of penicillin undoubtedly transformed the management of life-threatening bacterial infections. However, a less comfortable aspect of the antibiotic revolution was that within 10 years, over 80% of patients with acute bronchitis were receiving antibiotics without any evidence of clinical benefit. Antibiotic use inevitably causes collateral damage to the normal human flora and increases the risk of infection with antibiotic-resistant bacteria. The twin aims of antibiotic stewardship are to (i) ensure effective treatment for patients with bacterial infection and (ii) to provide convincing evidence and information to reduce unnecessary use and minimize collateral damage. 
  • Dumartin C, Rogues AM, Amadeo B, et al. (2011). Antibiotic stewardship programmes: legal framework and structure and process indicator in Southwestern French hospitals, 2005–2008. Journal of Hospital Infection, 77(2), 123-28.
    • French hospitals are required to implement antibiotic stewardship programmes (ABS) to improve antibiotic use. This analysis focuses on the legal framework of ABS and assesses its impacts on hospitals’ ABS development in Southwestern France. ABS implementation improved during the course of the study period, but little progress was made regarding time dedicated by pharmacists to antibiotic management and restrictive dispensation using stop-orders. Computerised tools, continuing education, and audits remained under-used, highlighting that some aspects require reinforcement. It appears crucial to monitor practical implementation to better approach ABS effectiveness and to adapt requirements. 
  • Fauci AS, Marston HD. (2014). The Perpetual Challenge of Antimicrobial Resistance. JAMA, 311(8), 1853-54. 
    • The emergence of multidrug-resistant bacteria and the rapid global spread of carbapenem-resistant Enterobacteriaceae (CRE) have recently captured public attention, and some have asked whether the ongoing public health and scientific “war” against drug-resistant microbes, particularly bacteria, can ever be won. In fact, the challenge of antimicrobial resistance is an enduring threat that likely will never be eliminated. The threat is due, in part, to the inherent ability of microbes to replicate rapidly and mutate, offering them an evolutionary advantage in fending off hazards to their survival. Addressing the threat of antimicrobial resistance is a never-ending challenge.
  • Ferri M, Ranucci E, Romagnoli P, et al. (2017). Antimicrobial resistance: A global emerging threat to public health systems. Critical Reviews in Food Science and Nutrition, 57(13), 2857-76.
    • Antimicrobial resistance (AMR) has become a global threat to public health systems in the world. This article presents an extensive overview of the epidemiology of AMR, with a focus on the link between food producing-animals and humans and on the legal framework and policies currently implemented at the EU level and globally. Responding to the AMR challenges could include an array of measures such as: designing more effective preventive measures at the farm-level to reduce the use of antimicrobials; developing of novel antimicrobials; strengthening of AMR surveillance systems; researching the ecology of resistant bacteria and resistant genes; increasing awareness of stakeholders on the consequences of AMR. The article concludes with specific recommendations structured around a holistic approach and targeted to different stakeholders. 
  • Fleming‐Dutra K, Hicks LA, Grundmann H. (2013). Surveillance for antimicrobial resistance and trends in antimicrobial utilization. In Infectious Disease Surveillance, Second Edition. 274-87. 
    • Antimicrobial resistance (AMR) is a leading infectious disease threat to public health. Public health action is needed to contain the spread of antimicrobial resistance and to prevent new resistance from emerging. This chapter describes important components of the fight against AMR including surveillance and monitoring of antimicrobial utilization. Methods of surveillance for AMR include active population-based surveillance, sentinel site surveillance systems, and aggregated antibiograms. Another approach is based on electronic laboratory data or case reports submitted to public health authorities. Antimicrobial utilization surveillance can be accomplished through the use of market-based sales data for outpatient antimicrobial use and through hospital reporting for inpatient antimicrobial use. Finally, a case study of the European Antimicrobial Resistance Surveillance Net is presented as an example of a well-functioning, multinational sentinel site surveillance system for antimicrobial resistance. 
  • Fridkin SK, Steward CD, Edwards JR, et al. (1999). Surveillance of Antimicrobial Use and Antimicrobial Resistance in United States Hospitals: Project ICARE Phase 2. Clinical Infectious Diseases, 29(2), 245-52.
    • The search for the means to understand and control the emergence and spread of antimicrobial resistance has become a public health priority. Project ICARE has established laboratory-based surveillance for antimicrobial resistance and antimicrobial use at a subset of hospitals participating in the National Nosocomial Infection Surveillance system. Data illustrate that for most antimicrobial-resistant organisms studied, rates of resistance were highest in the intensive care unit (ICU) areas and lowest in the outpatient areas. For most of the antimicrobial agents associated with this resistance, the rate of use was highest in the ICU areas, in parallel to the pattern seen for resistance. These comparative data on use and resistance among similar areas can be used as a benchmark by participating hospitals to focus their efforts on addressing antimicrobial resistance. 
  • Gandra S, Merchant AT, Laxminarayan R. (2016). A role for private sector laboratories in public health surveillance of antimicrobial resistance. Future Microbiology, 11, 709-12.
    • Policymakers have been slow to respond to the public health threat posed by antimicrobial resistance (AMR), despite increasing health and economic burdens. AMR surveillance data gives shape to an otherwise ill-defined problem, enabling policymakers to more effectively understand, quantify and manage the emergence and spread of resistance. At the patient level, antimicrobial susceptibility testing of clinical isolates can inform prescriber choice of therapeutic treatment. Susceptibility information at the population level allows for the monitoring of resistance trends across space and time, providing evidence on which to base standard treatment practices, antibiotic policies, and infection control guidelines. Going beyond susceptibility testing is critical; molecular analysis of global collections of isolates allows for a better understanding of the evolution and spread of resistant strains and genetic elements.
  • Grundmann H. (2014). Towards a global antibiotic resistance surveillance system: a primer for a roadmap. Upsala Journal of Medical Sciences, 119(2), 87-95.
    • The need for global data about the scale of antibiotic resistance (ABR) in a geographically explicit and timely manner has been identified by many stakeholders, including the World Health Organization. This primer helps to define objectives, scale, scope, and structure of possible future efforts. Stakeholders and their expected information demands were identified to generate an inventory of surveillance objectives. Putting ABR on the global health map is a daunting task that will require acceptance, agreements, and engagement but also concessions at many different levels. Given the existing gaps in the global diagnostic service landscape, only a step-wise approach which defines achievable aims, objectives, and milestones will succeed to produce a sustainable system of international co-operative surveillance of ABR. 
  • Hoffman SJ, Outterson K, et al. (2015). An international legal framework to address antimicrobial resistance. Bulletin of the World Health Organization, 93(2), 66.
    • Antimicrobial resistance is recognized as a grave threat to global health. The World Health Organization has prepared a draft Global action plan on antimicrobial resistance that will be discussed at this year’s World Health Assembly. However, more is required if the world is to grapple effectively with this huge and complex problem. Global collective action is required in three areas: (i) access, to ensure that the prevention tools, diagnostics, and therapies needed to reduce the infectious disease burden are available and affordable to everyone, everywhere; (ii) conservation, to reduce the need for antimicrobials and ensure their responsible use through prevention efforts, infection control, surveillance and appropriate prescriptions; and (iii) innovation, to develop the next generation of antimicrobials, vaccines, diagnostics and infection control technologies. 
  • Holmes AH, Moore LS, Sundsfjord A, et al. (2016). Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 387(10014), 176-87.
    • To combat the threat to human health and biosecurity from antimicrobial resistance, an understanding of its mechanisms and drivers is needed. The emergence of antimicrobial resistance in microorganisms is a natural phenomenon, yet antimicrobial resistance selection has been driven by antimicrobial exposure in health care, agriculture, and the environment. Onward transmission is affected by standards of infection control, sanitation, access to clean water, access to assured quality antimicrobials and diagnostics, travel, and migration. Strategies to reduce antimicrobial resistance by removing antimicrobial selective pressure alone rely upon resistance imparting a fitness cost, an effect not always apparent. Minimizing resistance should, therefore, be considered comprehensively, by resistance mechanism, microorganism, antimicrobial drug, host, and context; parallel to new drug discovery, broad-ranging, multidisciplinary research is needed across these five levels, interlinked across the health-care, agriculture, and environment sectors. Intelligent, integrated approaches, mindful of potential unintended results, are needed to ensure sustained, worldwide access to effective antimicrobials. 
  • Huijbers PM, Blaak H, de Jong MC, et al. (2015). Role of the Environment in the Transmission of Antimicrobial Resistance to Humans: A Review. Environmental Science & Technology, 49(20), 11993-2004.
    • This literature review was conducted to collect and categorize evidence for human exposure to various AMR bacteria in the environment.  AMR bacteria were detected at exposure-relevant sites, including recreational areas, drinking water, ambient air, and shellfish, and in fresh produce. More datasets were available for environmental compartments, including wildlife, water, soil, and air/dust. Quantitative data from exposure-relevant sites and environmental compartments were scarce. AMR bacteria were detected in the contamination sources wastewater and manure, and molecular data supporting their transmission from wastewater to the environment were found. The abundance of AMR bacteria at exposure-relevant sites suggests risk for human exposure. Of publications pertaining to both environmental and human isolates, only one compared isolates from samples that had a clear spatial and temporal relationship, and no direct evidence was found for transmission to humans through the environment. To what extent the environment, compared to the clinical and veterinary domains, contributes to human exposure needs to be quantified. 
  • Hwang TJ, Gibbs KA, Podolsky SH, et al. (2015). Antimicrobial stewardship and public knowledge of antibiotics. The Lancet Infectious Diseases, 15(9), 1000-01
    • Several US states have announced policies to promote responsible antibiotic use among health-care providers. In March 2015, in recognition of the public health threat and economic costs of antimicrobial resistance, the government made a commitment to reduce inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings by 2020 (compared with 2011). However, the national plan to combat antibiotic resistance does not address the effect of patient knowledge and expectations on the overconsumption of antibiotics. 
  • Jindal AK, Pandya K, Khan ID. (2015 ). Antimicrobial resistance: A public health challenge. Medical Journal Armed Forces India, 71(2), 178-81.
    • Since first reported in the 1940s, antimicrobial resistance has become a global concern. Though an evolutionary phenomenon, it is promulgated by faulty human behaviors. Today, a plethora of newer generation antimicrobials have become ineffective against previously susceptible organisms. This poses a challenge for healthcare managers and is compounded by the “discovery void” in the field of development of new antibiotics. If proper steps are not taken presently, the lurking fear of reaching a therapeutic dead end will become a reality. This paper aims at describing the pandemic of AMR from a public health perspective and suggesting strategies to deal with it in an effective and collaborative manner. 
  • Johnson LS, MacDougall C, Trivedi KK. (2016). The legislative momentum of antimicrobial stewardship: the US perspective. Current Treatment Options in Infectious Diseases, 8(2), 93-101.
    • United States federal agencies and the executive branch have issued reports characterizing antimicrobial resistance as threats to public health and national security. The state of California has implemented regulations requiring the establishment of antimicrobial stewardship programs (ASPs) in all acute-care hospitals and long-term care facilities. A goal of the National Action Plan for Combating Antimicrobial Resistance is the establishment of ASPs in acute care hospitals.Veterans Affairs and Department of Defense facilities have already adopted the ASP requirement; for non-federal hospitals, this mandate will likely be achieved through regulators such as the Centers for Medicaid and Medicare Services.
  • Khan ID, Gupta RM, Sen S, et al. (2017). Emerging Antimicrobial Resistance and Evolving Healthcare: Dangerous Crossroads for the Community and the Military. Journal of Archives in Military Medicine, 5(3), e12097-105.
    • Modern diagnostic and therapeutic procedures including advanced surgeries, organ transplants, and immunotherapy are pillared by antimicrobial therapy. Parallel to the rising incidence of infectious diseases, the menace of antimicrobial resistance (AMR) emerged worldwide. Developing countries are facing the brunt in epidemic proportions due to huge populations, substandard housing, overcrowding, rapid unplanned urbanization, deterioration in water and waste management systems, strained public health infrastructure, and limited resource allocation to healthcare. Simultaneously, AMR has adversely affected the outcome of military injuries. The rising problem of AMR is discouraging the development of newer antimicrobials by the pharmaceutical industry. There has been a considerable impetus towards concept development; however, the magnitude of the problem overshadows the progress made towards the control of AMR worldwide. There is a dire need to identify this threat, develop concerted multipronged strategy, develop infrastructure, foster expertise, and take coordinated and urgent steps to tackle the serious public health challenge. An intensified commitment needs to be taken up on a war footing at the individual, local, national, regional, and international levels. This article discusses the overall concept for developing countries.
  • Kirkland KB, Homa KA, Lasky RA, et al. (2012). Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Quality & Safety, 21, 1019-26
    • Evidence that hand hygiene (HH) reduces healthcare-associated infections has been available for almost two centuries. Yet HH compliance among healthcare professionals continues to be low, and most efforts to improve it have failed. This study sought to improve healthcare workers’ HH, and reduce healthcare-associated infections. The initiative was associated with a large and significant hospital-wide improvement in HH which was sustained through the following year and a significant, sustained reduction in the incidence of healthcare-associated infection. The observed increased incidence of the tracer condition supports the assertion that HH improvement contributed to infection reduction. Persistent variation in HH performance among different groups requires further study. 
  • Kumar, S. Ganesh, et al. (2013). Antimicrobial resistance in India: A review. Journal of Natural Science Biology and Medicine, 4(2), 286-91.
    • Antimicrobial resistance (AMR) is an important concern for the public health authorities at the global level. However, in developing countries like India, recent data showed an increase in the burden of antimicrobial resistance. Research related to antimicrobial use, determinants and development of antimicrobial resistance, regional variation, and interventional strategies according to the existing healthcare situation in each country is a big challenge. This paper discusses the situational analysis of AMR with respect to its problem, determinants, and challenges ahead with strategies required in future to reduce the burden in India. The results of this study suggest that hospital-based studies show a higher and varied spectrum of resistance in different regions while there are limited numbers of community-based studies at a country level. Gaps exist in the structure and functioning of the public health care delivery system with regard to quantification of the problem and various determining factors related to antimicrobial resistance. There is an urgent need to develop and strengthen antimicrobial policy, standard treatment guidelines, a national plan for containment of AMR and research related to public health aspects of AMR at community and hospital level in India. 
  • Lammie SL, Hughes JM. (2016). Antimicrobial Resistance, Food Safety, and One Health: The Need for Convergence. Annual review of Food Science and Technology, 7, 287-312.
    • Antimicrobial resistance is a complex, multifaceted, urgent global health problem. There is increasing concern about the emergence of multidrug-resistant superbugs. These superbugs result in infections responsive to treatment with few if any currently available antimicrobial agents, reviving memories of the preantibiotic era and evoking concerns about a postantibiotic era. Addressing this urgent threat requires implementation of a multifaceted strategy that has been articulated in the past few years; implementation will require sustained political will, investment in systems and research, and a One Health approach involving improved communication, cooperation, and collaboration among the many professional disciplines and organizations with important roles to play at the intersection of human, animal, and environmental health.
  • Laxminarayan R, Sridhar D, Blaser M, et al. (2016). Achieving global targets for antimicrobial resistance. Science, 353(6302), 874-75.
    • Antimicrobial resistance (AMR) has captured the attention and concern of the public health community and global leaders. In September 2016, a high-level meeting of the United Nations General Assembly (UNGA) discussed how countries can cooperate to preserve global access to effective antimicrobials. This is only the fourth health issue to bring together heads of state at the UNGA for a rare opportunity to set a global agenda to combat the crisis. Setting targets for reducing drug-resistant infections, adequate financing for global action, and defining the global health architecture to address AMR should be elements of a UN plan. 
  • Laxminarayan R, Duse A, Wattal C, et al. (2013). Antibiotic resistance—the need for global solutions. The Lancet Infectious Diseases, 13(12), 1057-98.
    • The causes of antibiotic resistance are complex and include human behavior at many levels of society; the consequences are felt globally. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensable in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. This article describes the global situation of antibiotic resistance, its major causes and consequences, and identifies key areas in which action is needed.
  • Lee GM, Hartmann CW, Graham D, et al. (2012). Perceived impact of the Medicare policy to adjust payment for health care-associated infections. American Journal of Infection Control, 40(4), 314-19.
    • In 2008, the Centers for Medicare and Medicaid Services (CMS) ceased additional payment for hospitalizations resulting in complications deemed preventable, including several health care-associated infections. This study seeks to understand the impact of the CMS payment policy on infection prevention efforts. Results showed that infection preventionists reported greater hospital attention to preventing targeted HAIs as a result of the CMS nonpayment policy. Whether the increased focus and greater engagement in HAI prevention practices have led to better patient outcomes is unclear.
  • Lee Y, Wakabayashi M. (2013). Key informant interview on antimicrobial resistance (AMR) in some countries in the western Pacific region. Globalization and Health, 9(1), 34-41.
    • Interviews were conducted with a series of key informants – predominantly senior government staff – to assess their awareness of the antimicrobial resistance and potential interventions proposed in the policy package. AMR was widely recognized as a problem, and a lack of a coherent, comprehensive and plan or strategy was noted. Surveillance was often seen as weak and fragmented even where presented. Most respondents stressed the need for national and local plans to combat AMR. 
  • Leung E, Weil DE, Raviglione M, et al. (2011). The WHO policy package to combat antimicrobial resistance. Bulletin of the World Health Organization, 8995, 390-92.
    • Antimicrobial resistance is not a new problem and is a threat to all branches of medical and public health practice. It challenges the control of infectious diseases, jeopardizes progress on health outcomes by increasing morbidity and mortality and imposes huge costs on societies. In the European Union, about 25 000 patients die each year from infections caused by selected multidrug-resistant bacteria and the associated costs are estimated at about 1.5 billion euros per year. In the United States, infections with pathogens resistant to antimicrobials cost the health-care system in excess of US$ 20 billion annually and generate more than 8 million additional hospital days. The annual societal costs exceed US$ 35 billion. Strategic interventions to control antimicrobial resistance have been known for some time, but national and global responses have been inadequate. Strong leadership and political will be required to bring about bold changes in policies, organize health systems and legislative structures as required, and translate knowledge into practice.  
  • Llor C, Bjerrum L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229-41
    • Antimicrobial resistance is a global health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients, and the performance of more pragmatic studies in primary care with outcomes that are of clinicians’ interest.
  • Lutgring JD, Granados CAD, McGowan JE. (2017). Antimicrobial Resistance: An International Public Health Problem. Antimicrobial Drug Resistance, 1519-28. 
    • In recent years, the problem of antimicrobial resistance has been recognized and addressed by international, regional, and national public health agencies, authorities, and professional societies. The worsening problem of antimicrobial resistance now jeopardizes the medical advances of the past century. However, action plans to minimize this threat have been developed by many public health agencies around the globe. This focus is likely to increase among public health agencies in the coming years. Several facets of the problem involve the relationship between human and animal use of antimicrobial agents. This chapter summarizes the components of the cost of resistance from a public health perspective and contrasts this perspective to other societal perspectives. It then reviews strategies at several different levels of responsibility, ranging from the patient care provider to international agencies. Finally, it considers appropriate public health responses according to the resources available for control. 
  • McArthur AG,  Tsang KK. (2017). Antimicrobial resistance surveillance in the genomic age. Annals of the New York Academy of Sciences, 1388(1), 78-91.
    • The loss of effective antimicrobials is reducing our ability to protect the global population from infectious disease. However, the field of antibiotic drug discovery and the public health monitoring of antimicrobial resistance (AMR) is beginning to exploit the power of genome and metagenome sequencing. The creation of novel AMR bioinformatics tools and databases and their continued development will advance our understanding of the molecular mechanisms and threat severity of antibiotic resistance, while simultaneously improving our ability to accurately predict and screen for antibiotic resistance genes within environmental, agricultural, and clinical settings. To do so, efforts must be focused toward exploiting the advancements of genome sequencing and information technology. Currently, AMR bioinformatics software and databases reflect different scopes and functions, each with its own strengths and weaknesses. A review of the available tools reveals common approaches and reference data but also reveals gaps in our curated data, models, algorithms, and data-sharing tools that must be addressed to conquer the limitations and areas of unmet need within the AMR research field before DNA sequencing can be fully exploited for AMR surveillance and improved clinical outcomes.
  • Metlay JP, Powers JH, Dudley MN, et al. (2006). Antimicrobial drug resistance, regulation, and research. Emerging Infectious Diseases, 12(2), 183-91.
    • Innovative regulatory and legislative measures to stimulate and facilitate the development of new antimicrobial drugs are needed. This perspective piece discusses approaches that can aid regulatory decision making for the treatment of resistant infections and minimization of resistance. The authors also outline current and future measures that regulatory agencies may employ to help control resistance and promote drug development.  
  • Morency-Potvin P, Schwartz DN, Weinstein RA. (2017). Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship. Clinical microbiology reviews, 30(1), 381-407.
    • Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in healthcare settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, the authors emphasize how the evolution of clinical microbiology has reinforced the importance of clinical microbiologists’ collaboration with antimicrobial stewardship programs. 
  • Okeke IN. (2010). Poverty and Root Causes of Resistance in Developing Countries. In: Antimicrobial Resistance in Developing Countries. New York: Springer.
    • Antimicrobial use provides selective pressure for resistant strains but there are other factors that combine with use to promote the emergence and spread of resistant bacteria, mobile elements, and genes. Many of these factors are only superficially understood, if at all, and are complicated to study. Comparative antimicrobial resistance data from populations with different risk factors for resistance are hard to come by and inevitably suffer from bias. Nonetheless, a few studies document regional variations in resistance and some provide clues about factors that might exacerbate resistance. Data from these studies appear to suggest that antimicrobial misuse, prophylactic use, diagnostic imprecision, and interpersonal spread are key factors in the selection and dissemination of resistant strains. All these factors are promoted by poverty at the individual patient, health system, and national levels. 
  • Ondoa P, van der Broek A, Jansen C, et al. (2017). National laboratory policies and plans in sub-Saharan African countries: gaps and opportunities. African Journal of Laboratory Medicine, 6(1), 578-98.

    • This study describes the extent to which laboratories are addressed in the national health policies and plans. The availability of laboratory policy and plan implementation can be improved by strictly applying a more standardized methodology for policy development, using harmonized norms to set targets for improvement and intensifying the establishment of directorates of laboratory services directly under the authority of Ministries of Health. Horizontal programmes such as the Global Health Security Agenda could provide the necessary impulse to take the least advanced countries on board. 

  • Parsons LM, Somoskövi Á, Gutierrez C, et al. (2011). Laboratory Diagnosis of Tuberculosis in Resource-Poor Countries: Challenges and Opportunities. Clinical Microbiology Reviews, 24(2), 314-350.
    • With an estimated 9.4 million new cases globally, tuberculosis (TB) continues to be a major public health concern. This review describes several new and established methods as well as the issues and challenges associated with implementing quality tuberculosis laboratory services in high-burden countries. Recently, the WHO has endorsed some of these novel methods, and they have been made available at discounted prices for procurement by the public health sector of high-burden countries. In addition, international and national laboratory partners and donors are currently evaluating other new diagnostics that will allow further and more rapid testing in point-of-care settings. While some techniques are simple, others have complex requirements, and therefore, it is important to carefully determine how to integrate them within a country’s national diagnostic algorithm. Finally, the successful implementation of these methods is dependent on key partnerships in the international laboratory community and ensuring that adequate quality assurance programs are inherent in each country’s laboratory network. 
  • Perez F, Villegas MV. (2015). The role of surveillance systems in confronting the global crisis of antibiotic-resistant bacteria. Current Opinion in Infectious Diseases, 28(4), 375-83.
    • It is widely accepted that infection control, advanced diagnostics, and novel therapeutics are crucial to mitigate the impact of antibiotic-resistant bacteria. The role of global, national, and regional surveillance systems as part of the response to the challenge posed by antibiotic resistance is not sufficiently highlighted. This article provides an overview of contemporary surveillance programs, with emphasis on gram-negative bacteria. 
  • Sadak M, Cramp E, Ashiru-Oredope D. (2016). Antimicrobial Resistance and Stewardship in National Action Plans. Current Treatment Options in Infectious Diseases, 8(2), 57-71.
    • Tackling antimicrobial resistance (AMR) has global focus due to the significant threat resistance poses to human and animal health and its potential impact on the global economy as a result of reduced productivity caused by sickness and higher treatment costs. Therefore, the importance of strengthening health systems ensuring antimicrobial agents are used and accessed appropriately has never been more important. A potential solution to combating AMR globally is implementing comprehensive and sustainably resourced national plans based on a multi-sector approach. This paper seeks to explore the global adoption and implementation of national action plans and specifically the use of antimicrobial stewardship strategies to promote the optimal use of antimicrobials.  
  • Shaban RZ, Cruickshank M, Christiansen K. (2013). National surveillance and reporting of antimicrobial resistance and antibiotic usage for human health in Australia. Canberra: Antimicrobial Resistance Standing Committee, Australian Heath Protection Principal Committee.

    • Antimicrobial resistance has been recognized as a global health priority by the World Health Organization. Australian governments have taken significant action in establishing two committees to oversee national initiatives to prevent and contain antimicrobial resistance in Australia. This report examines antimicrobial resistance surveillance models, activities undertaken by Australian surveillance units; activities undertaken by the Australian Group on Antimicrobial Resistance, and the National Antimicrobial Utilisation Program, and examines how reports from routine diagnostic laboratories might provide a source of data to contain antimicrobial resistance. 

  • Shallcross LJ, Howard SJ, Fowler T, et al. (2015). Tackling the threat of antimicrobial resistance: from policy to sustainable action. Phil. Trans. R. Soc. B, (1670), 20140082-87.
    • Antibiotics underpin all of modern medicine. These drugs have revolutionized how we practice medicine, but we are in a constant evolutionary battle to evade microbial resistance and this has become a major global public health problem. We have overused and misused these essential medicines both in the human and animal health sectors and this threatens the effectiveness of antimicrobials for future generations. We can only address the threat of antimicrobial resistance (AMR) through international collaboration across human and animal health sectors integrating social, economic and behavioral factors. Global organizations are rising to the challenge but we must act now to avoid a return to a pre-antibiotic era. 
  • Sumpradit N, Wongkongkathep S, Poonpolsup S, et al. (2017). New chapter in tackling antimicrobial resistance in Thailand. BMJ, 358, h3415-31.
    • This article provides a description of Thailand’s experience in developing its national strategic plan on antimicrobial resistance. It highlights the need for sustained political commitment and multisectoral collaboration. 
  • Tangcharoensathien V, Sattayawutthipong W, Kanjanapimai S, et al. (2016). Antimicrobial resistance: from global agenda to national strategic plan, Thailand. Bulletin of the World Health Organization, 95(8), 599-606.
    • Antimicrobial resistance poses a serious security threat to global health. Global attention and national concern pushed the Thai government to take action against antimicrobial resistance and the government has endorsed a national strategic plan on antimicrobial resistance. This plan is comprised six strategic actions and five targets. A national steering committee guides the plan’s implementation and a module to assess the prevalence of household antibiotic use and antimicrobial resistance awareness has been embedded into the biennial national health survey. A national system for the surveillance of antimicrobial consumption has also been initiated. 
  • Tenover FC. (2006). Mechanisms of Antimicrobial Resistance in Bacteria. American Journal of Medicine, 119(6), S3-10.
    • The treatment of bacterial infections is increasingly complicated by the ability of bacteria to develop resistance to antimicrobial agents. Antimicrobial agents are often categorized according to their principal mechanism of action. Mechanisms include interference with cell wall synthesis, inhibition of protein synthesis, interference with nucleic acid synthesis, inhibition of a metabolic pathway, and disruption of bacterial membrane structure. Bacteria may be intrinsically resistant to several classes of antimicrobial agents or may acquire resistance by de novo mutation or via the acquisition of resistance genes from other organisms. Acquired resistance genes may enable a bacterium to produce enzymes that destroy the antibacterial drug, to express efflux systems that prevent the drug from reaching its intracellular target, to modify the drug’s target site, or to produce an alternative metabolic pathway that bypasses the action of the drug. Acquisition of new genetic material by antimicrobial-susceptible bacteria from resistant strains of bacteria may occur through conjugation, transformation, or transduction, with transposons often facilitating the incorporation of the multiple resistance genes into the host’s genome or plasmids. Use of antibacterial agents creates selective pressure for the emergence of resistant strains. Herein 3 case histories are reviewed to illustrate the varied ways in which resistant bacteria develop. 
  • Turnidge J, Meleady K, Poole N. (2016). Developing a national surveillance system for antimicrobial use and resistance in Australia: AURA. Infection Disease & Health, 21(3), 123.
    • Australia has a high rate of antimicrobial use (AU) compared with other countries, and increasing rates of some types of antimicrobial resistance (AMR). The foundation of a comprehensive national surveillance system for AU and AMR has been established as part of the AURA Surveillance System. AURA coordinates data from a range of collections produce integrated surveillance information and reports about the current state of play, trends over time, and where feasible, the interrelationships between AMR and AU.
  • Uchil RR, Kohli GS, Katekhaye VM, et al. (2014). Strategies to combat antimicrobial resistance. Journal of Clinical and Diagnostic Research, 1-4.
    • The global burden of antimicrobial resistance is rising and is associated with increased morbidity and mortality in clinical and community setting. The spread of antibiotic resistance to different environmental niches and development of superbugs have further complicated the effective control strategies. International, national and local approaches have been advised for control and prevention of antimicrobial resistance. Rational use of antimicrobials, regulation on over-the-counter availability of antibiotics, improving hand hygiene and improving infection prevention and control are the major recommended approaches. Thorough understanding of resistance mechanism and innovation in new drugs and vaccines is the need. A multidisciplinary, collaborative, regulatory approach is demanded for combating antimicrobial resistance. 
  • van de Sande-Bruinsma N, Wong DLF. (2014). WHO European strategic action plan on antibiotic resistance: How to preserve antibiotics. Journal of Pediatric Infectious Diseases, 9(3), 127-34.
    • The impact of antimicrobial resistance (AMR) is enormous, not only through increased health care costs, but also loss of income and loss of lives. As such, antimicrobial resistance is not only a medical issue, but also a social and economic one. In addition, the emergence of AMR does not respect borders, man-made or between animal species, therefore requiring an international effort and a comprehensive or One Health approach. This paper describes the efforts that are being taken at WHO Regional Office for Europe to support countries in containing antibiotic resistance, based on the 7 strategic objectives of the WHO European strategic action plan on antibiotic resistance. 
  • Wernli D, Jørgensen PS, Harbarth S, et al. (2017). Antimicrobial resistance: The complex challenge of measurement to inform policy and the public. PLoS Medicine, 14(8), e1002378-87.
    • Antimicrobial resistance (AMR) is developing in many pathogenic bacteria, threatening to compromise the effectiveness of crucial medical treatments. Member States of the United Nations (UN) have reiterated their commitment to tackling AMR at the UN General Assembly held in New York City on 21 September 2016. The main challenge is now the implementation of the Global Action Plan adopted by the World Health Organization (WHO) in 2015. There are currently large information gaps about the global governance of AMR regarding both the magnitude of the problem and national responses. Expanding national and subnational monitoring by integrating measurements ranging from assessments of drivers of AMR to responses can increase political buy-in, societal participation, and implementation of agreed policies. WHO should lead the way to expand monitoring of progress regarding AMR control, but a broad coalition of global health actors is needed to build a robust approach in a significant number of countries. 
  • Wernli D, Haustein T, Conly J, et al. (2011). A Call for Action: The Application of the International Health Regulations to the Global Threat of Antimicrobial Resistance. PLoS Medicine, 8(4), e1001022-28.
    • The public health threat of antimicrobial resistance (AMR) is growing and needs to be addressed urgently. The International Health Regulations (IHR), a legally binding agreement that aims to prevent, protect against, control, and provide a public health response to the international spread of disease, deserve critical examination with regard to their applicability to AMR. The authors argue that the emergence and spread of antimicrobial-resistant bacteria, especially those involving new pan-resistant strains for which there are no suitable treatments, may constitute a public health emergency of international concern and are notifiable to the World Health Organization under the IHR notification requirement. The use of the IHR framework could considerably improve our response to emerging AMR threats. As more governments start to take the threat of AMR seriously, there is a window of opportunity for having a healthy debate about the applicability of the IHR to AMR.
  • Woolhouse M, Ward M, van Bunnik B, et al. (2015). Antimicrobial resistance in humans, livestock and the wider environment. Phil. Trans. R. Soc. B, 370(1670), 20140083-90.
    • Antimicrobial resistance (AMR) in humans is inter-linked with AMR in other populations, especially farm animals, and in the wider environment. The relatively few bacterial species that cause disease in humans, and are the targets of antibiotic treatment, constitute a tiny subset of the overall diversity of bacteria that includes the gut microbiota and vast numbers in the soil. However, resistance can pass between these different populations; and homologous resistance genes have been found in pathogens, normal flora and soil bacteria. Farm animals are an important component of this complex system: they are exposed to enormous quantities of antibiotics and act as another reservoir of resistance genes. Surveillance of bacterial disease, drug usage and resistance in livestock is still relatively poor, though improving, but achieving better antimicrobial stewardship on the farm is challenging: antibiotics are an integral part of industrial agriculture and there are very few alternatives. Human production and use of antibiotics either on the farm or in the clinic is but a recent addition to the natural and ancient process of antibiotic production and resistance evolution that occurs on a global scale in the soil. Viewed in this way, AMR is somewhat analogous to climate change, and that suggests that an intergovernmental panel, akin to the Intergovernmental Panel on Climate Change, could be an appropriate vehicle to actively address the problem. 
  • World Health Organization. (2001). Surveillance standards for antimicrobial resistance. Geneva: World Health Organization.
    • This manual provides national agencies with a framework within which existing surveillance of communicable disease and infection can be reviewed in order to determine the priorities for epidemiological surveillance of diseases caused by microorganisms exhibiting antimicrobial resistance. The manner of implementation of antimicrobial resistance surveillance most appropriate in a particular country will be determined by a number of factors, including the range of diseases of public health significance, the organization of healthcare services and the resources available. Although a national implementation plan involves a national reference laboratory in collaboration with epidemiological expertise, many of the recommendations can be implemented by local clinical microbiology laboratories. Hence these guidelines can be useful for professionals in a number of positions in the health care system including medical officers in the ministry of health, public health microbiologists and epidemiologists and clinical microbiologists.
  • World Health Organization. (2014). Antimicrobial Resistance Global Report on Surveillance. Geneva: World Health Organization.
    • Determining the scope of the problem is essential for formulating and monitoring an e‚ective response to AMR. This WHO report, produced in collaboration with Member States and other partners, provides as accurate a picture as is presently possible of the magnitude of AMR and the current state of surveillance globally
  • World Health Organization. (2015). Action Agenda for Antimicrobial Resistance in the Western Pacific Region. Geneva: World Health Organization .
    • The rapid emergence and spread of antimicrobial resistance present health-care systems with serious challenges and threatens their ability to effectively treat severe bacterial infections. Without effective antimicrobials, the success of modern medicine could be compromised. Immediate and coordinated measures must be taken by Member States in the Western Pacific Region and globally to safeguard the effectiveness of antimicrobials and facilitate the development of new antimicrobial medicines.
  • World Health Organization – South-East Asia Regional Office. (2015). Antimicrobial resistance: Report of a regional meeting, Jaipur, India, 10-13 November 2014. Geneva: World Health Organization.
    • Antimicrobial Resistance (AMR) is an increasingly serious threat to global public health. The problem is so serious that it threatens the achievements of modern medicine. A post-antibiotic era in which common infections and minor injuries can kill is a very real possibility for the 21st century. The WHO Regional Office for South-East Asia organized the SEA Regional Meeting on Antimicrobial Resistance (AMR) to review the status of development and implementation of national action plans on AMR, to advocate with Member States for acceleration of national efforts to build capacities needed for implementation of the Jaipur Declaration on AMR and the SEA Regional Strategy on AMR, to discuss the gaps and challenges hampering national efforts and suggest the way forward. 
  • World Health Organization. (2015). Asia Pacific Strategy for Emerging Diseases Progress Report 2015. Manila: WHO Regional Office for the Western Pacific.
    • It has been nine years since APSED was conceived as the main strategic framework for the Asia Pacific Region to develop the IHR core capacity requirements. The APSED evaluation conducted in 2015 concluded that considerable progress has been made in several areas, including the establishment of event-based surveillance, training field epidemiologists, improving the effectiveness of rapid response teams (RRTs) and public health laboratory capacity for basic diagnosis. Other areas of good progress are coordination between human and animal health ministries for zoonotic diseases and regional-level surveillance, and information sharing and response. There is mixed evidence of progress in the area of risk communication capacity, IPC and consistent risk assessment at the national level.
  • World Health Organization. (2015). Global Antimicrobial Resistance Surveillance System (GLASS). Geneva: World Health Organization.
    • In May 2015, the Sixty-eighth World Health Assembly adopted the global action plan on antimicrobial resistance (AMR). One of the five strategic objectives of the action plan is to strengthen the AMR evidence base through enhanced global surveillance. To support this objective, the Global Antimicrobial Resistance Surveillance System (GLASS) aims to establish a global standardized approach to the collection, analysis, and sharing of data.
  • World Health Organization. (2015). Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. Geneva: World Health Organization.
    • These guidelines provide (i) evidence-based recommendations on the core components of infection prevention and control (IPC) programmes that are required to be in place at the national and acute facility level to prevent HAI and to combat AMR through IPC good practices; (ii) to support countries and healthcare facilities to develop or strengthen IPC programmes and strategies through the provision of evidence- and consensus-based guidance that can be adapted to the local context, while taking account of available resources and public health needs. 
  • World Health Organization. (2015). Worldwide country situation analysis: response to antimicrobial resistance. Geneva: World Health Organization.
    • A multi-stage analytical tool was developed to assess the situation at the national level. The tool was based on existing WHO assessment tools and reflected the elements contained in the policy package to address antimicrobial resistance that was issued on World Health Day 2011. Country authorities were asked to complete a questionnaire on their existing strategies, systems and activities. The questionnaires were completed either by the authorities themselves through self-assessment or at an interview with a WHO officer on the occasion of a country visit. This report presents the overall findings of the survey. It provides an analysis, by region and globally, of the initiatives underway to address antimicrobial resistance and identifies areas in which more work is required.
  • World Health Organization. (2016). National Action: The Rising Tide for Global Change on Antimicrobial Resistance. Geneva: World Health Organization.
    • Antimicrobial resistance is a global problem. Infections and the emergence of resistance to the drugs used to prevent and treat them have readily spread across geographical borders, threatening global health security. Rapid transport of infectious agents and their resistant genes has been facilitated by increasing global connectivity, obliging countries of all income levels to take responsibility to contain the spread.
  • World Health Organization – Eastern Mediterranean Regional Office. (2017). Assessment of essential public health functions in countries of the Eastern Mediterranean Region. Geneva: World Health Organization.
    • The purpose of this initiative is to provide evidence-informed recommendations for improving public health capacity and performance in Member States. This aim can be achieved through: (i) providing a baseline status of national public health services and capacities, based on an objective assessment; (ii) identifying areas of strength as well as areas for further development and actions needed at country level to strengthen EPHF; (iii) convening a national policy dialogue that brings together different stakeholders to reach consensus on a proposed action plan and the way forward; iv) developing institutional capacity within the Region to undertake an assessment of EPHF.
  • Xiao Y, Li L. (2016). China’s national plan to combat antimicrobial resistance. The Lancet Infectious Diseases, 16(11), 1216-18.
    • The Chinese Government recently announced a national action plan (NAP) to combat antimicrobial resistance. Given the current global situation regarding antimicrobial resistance, the content of China’s NAP deserves attention from the public health community. 
  • Zumla A, Azhar EI, Hui DS, et al. (2018). Global spread of antibiotic-resistant bacteria and mass-gathering religious events. The Lancet Infectious Diseases, 18(5), 488-90.
    • Although the global threat of AMR has repeatedly been attributed to the inappropriate use of antibiotics in human beings and in animal husbandry, AMR in animals and people without previous exposure to antibiotics has been observed, highlighting the complex evolution and transmission dynamics between people, domestic animals, the environment, and wildlife. Defining the global burden of symptomatic and asymptomatic infections, transmission risk, determinants of resistance evolution, and patterns of transmission and spread of AMR between different reservoirs and between human populations are now a global research priority. These goals will require concerted multidisciplinary collaborative efforts across all continents. There remains an urgent need to develop consensus and coordination between various research groups on common surveillance, research priorities, methodology, data collection, and analysis protocols, with sharing of data and coordination.