3. Antimicrobial resistance

A functional system in place for the national response to prevent and combat antimicrobial resistance (AMR) with a One Health approach, including:

  • Multisectoral work spanning human, animal, crops, food safety and environmental aspects – this comprises developing and implementing a national action plan to combat AMR, consistent with the global action plan on AMR.
  • Surveillance capacity for AMR and antimicrobial use at the national level, following and using internationally agreed systems such as the WHO Global Antimicrobial Resistance Surveillance System (GLASS) and the OIE global database on use of antimicrobial agents in animals.
  • Prevention of AMR in healthcare facilities, food production and the community, through infection prevention and control measures.
  • Ensuring appropriate use of antimicrobials, including assuring quality of available medicines, conservation of existing treatments and access to appropriate antimicrobials when needed, while reducing inappropriate use.

Impact

Decisive and comprehensive action to prevent the emergence and reduce the spread of AMR. Countries will (in line with the global action plan) increase awareness of AMR risks and how to respond to them; strengthen surveillance and laboratory capacity; enhance infection prevention and control activities; ensure uninterrupted access to essential antimicrobials of assured quality; regulate and promote the appropriate use of antimicrobials in human medicine, veterinary medicine, food production and other fields as appropriate; and support initiatives to foster the development and appropriate use of new antimicrobial agents, vaccines and diagnostic tools.

Monitoring and evaluation

(1) Multisectoral national action plan to combat AMR has been produced and made public. (2) Implementation of the AMR national action plan/sector plans, with monitoring and yearly reporting on progress (including reporting to the international level) is in place. (The JEE tool reviews the country’s self-assessed response to the global monitoring survey on AMR.)

Benchmark 3.1

Effective multisectoral coordination on AMR

Objective: To develop and implement a multisectoral national action plan on AMR

01
No capacity
No national action plan for AMR.
02
Limited capacity
Actions to achieve this level:
  • Establish a national multisectoral AMR coordinating committee.
  • Undertake a situation analysis to identify major risks for development and transmission of AMR, and where the impact of resistance would be greatest.
  • Identify programmes and activities relating to key AMR objectives that need to be developed or scaled up.
  • Identify a health ministry lead for AMR, develop a clear terms of reference and coordinate activities of the relevant ministries on AMR and stewardship.
03
Developed capacity
Actions to achieve this level:
  • Develop a plan of action to address AMR in line with the Global Action Plan (GAP) on AMR.
  • Submit a plan for approval through relevant governance mechanisms (such as office of head of state, cabinet, or ministries of health and agriculture).
  • Organize effective coordination through regular meetings.
04
Demonstrated capacity
Actions to achieve this level:
  • Identify priority actions (based on risk and feasibility) from the national action plan, develop an implementation plan with responsible agencies with established timelines, and begin implementation of these actions.
  • Develop and implement an AMR national action plan monitoring framework.
  • Review plans and progress through regular meetings of the AMR governance committee.
  • Identify and map sustained funding for planned activities in the AMR national action plan.
05
Sustainable capacity
Actions to achieve this level:
  • Dedicate sustain funding for planned activities in the AMR national action plan.
  • Ensure key activities are incorporated in plans and budgets of relevant programmes and agencies.
  • Ensure regular monitoring of progress with data submitted to regional and global levels.
  • Define clearly specified actions within planning and governance mechanisms for all key sectors involved.
  • Identify potential barriers and/or challenges to implementing the national action plan and approaches to overcome these barriers.

Benchmark 3.2:

Surveillance system of AMR is in place

Objective: To develop a national AMR surveillance system that integrates surveillance of AMR in pathogens of concern to human and animal health and agriculture

01
No capacity
None of the laboratories that conduct antibiotic susceptibility testing are generating data (antibiotic susceptibility and accompanying clinical and epidemiological data) and there is no surveillance system reporting on AMR.
02
Limited capacity
Actions to achieve this level:
  • Designate a national coordinating centre to oversee the development and functioning of the national AMR surveillance system.
  • Complete an assessment of existing laboratory capacities for identification and antibiotic susceptibility testing of common bacteria including Mycobacterium tuberculosis.
  • Define priority specimens, pathogens and drug–bug combinations for national reporting.
  • Designate a national reference laboratory to support AMR surveillance and develop SOPs for verification and additional testing and identify an external quality assessment provider for the national reference laboratory.
  • Designate laboratories and secure laboratory reagents to conduct detection and reporting of some priority AMR pathogens.
  • Establish One Health AMR training and mentorship programmes for national and country laboratories.
  • Develop and initiate training programmes for data collection and reporting of AMR at national and regional levels.
  • Initiate AMR surveillance at pilot or representative regional and referral hospitals.
03
Developed capacity
Actions to achieve this level:
  • Define laboratory standards and capacity requirements that laboratories must meet to participate in national surveillance.
  • Develop steps to strengthen laboratory capacity to sustainably identify and perform identification and antibiotic susceptibility testing of common bacteria including M. tuberculosis.
  • Establish an external quality assessment programme for the national reference laboratory and ensure that the national reference laboratory can conduct confirmatory or additional testing.
  • Define national AMR surveillance objectives and develop a national AMR surveillance strategy.
  • Establish SOPs, protocols and databases for surveillance data, a system for reporting to ministries of health and agriculture, and a mechanism to analyse data and report back to facilities and to WHO.
  • Develop a national surveillance protocol including: surveillance targets, laboratory standards, priority specimens, pathogens and drug–bug combinations, defined datasets, metrics, data production, analysis and reporting, quality management, monitoring and evaluation).
  • Designate functional AMR surveillance sites.
04
Demonstrated capacity
Actions to achieve this level:
  • Evaluate existing AMR and drug-resistant TB surveillance systems, disseminate results and develop an action plan for implementation of a national surveillance system.
  • Establish external quality assessment programme for all laboratories (human and animal) generating data for AMR surveillance.
  • Develop and maintain sustainable support for AMR and drug-resistant TB surveillance infrastructure including laboratory supply chain.
  • Expand AMR testing and surveillance to include other clinical sites and/or other areas of the healthcare system (such as private sector).
  • Collect population-based denominators, such as those recommended by WHO GLASS.
  • Develop and implement strategies for monitoring national AMR and drug-resistant TB.
05
Sustainable capacity
Actions to achieve this level:
  • Enhance monitoring of antibiotic-resistance patterns and genotyping, as well antibiotic usage and management practices at multiple points in the production chain for food animals and retail meat.
  • Disseminate reports relating to measuring the proportion of AMR pathogens among specimens or isolates, results from participation in international external quality assessment rounds of the national reference laboratory, and incidence of infections caused by AMR pathogens at sentinel sites (community and hospital acquired)
  • Demonstrate the use of this information for policy changes, improving facilities and adapting prevention and control strategies.

Benchmark 3.3:

Infection prevention and control is in place

Objective: To develop a functioning infection prevention and control system for healthcare facilities and farms

01
No capacity
  • Systematic efforts, national infection prevention and control (IPC) programmes and “water, sanitation and hygiene” (WASH) standards, or responsible persons for infection prevention and control in human healthcare facilities to promote infection prevention and prevent transmission of resistant bacteria in the animal food production sector either do not exist or are at the development stage.
02
Limited capacity
Actions to achieve this level:
  • Review WHO recommendations on core components for effective IPC programmes and the national and facility practical manuals supporting their implementation.
  • Use IPC assessment tools (IPCAT) to assess the core components of IPC programmes at the national (IPCAT2; tool 2) and facility (IPCAF; facility level) levels and identify precise areas/ core components requiring action.
  • Develop and implement an action plan, informed by assessment results and following the five-step cycle described in the practical manuals, that addresses the identified priority core components at the national and facility levels (at least at major hospital centres), core component one (IPC programme) and core component eight (WASH), according to the WHO requirements/action checklists.
  • Establish a National IPC Committee and develop National IPC Committee terms of reference and local IPC committees at district and/or facility level, if an action plan is not in place.
  • Develop a national IPC policy and plan for animal health.
03
Developed capacity
Actions to achieve this level:
  • Develop national IPC guidelines for human and animal health sectors (IPC in animal production).
  • Identify and allocate adequate resources to support selected healthcare facilities/farms to implement IPC action plans, including IPC guidelines.
  • Use IPC assessment tools at national (IPCAT2) and facility (IPCAF) levels to identify precise areas requiring additional activities to improve or put in place additional IPC core components and to guide the development of a detailed improvement plan of action.
  • Implement the action plan, informed by assessment results and following the five-step cycle described in the practical manuals, according to the WHO requirements/action checklists for the priority core components identified.
  • Refer to the recommendations and requirements for IPC guidelines, and train adequate healthcare workers on issued guidelines.
  • Monitor IPC and WASH implementation in selected healthcare facilities using IPCAF, hand hygiene self-assessment framework, hand hygiene compliance observation tools WASH FIT tool.
04
Demonstrated capacity
Actions to achieve this level:
  • Use the national IPC assessment tool (IPCAT2) to identify precise areas still requiring action and update the plan of action.
  • Mandate and support IPC improvement at all healthcare facilities, recommending the use of the infection prevention and control assessment framework ( IPCAF ) and the WASH fit tool and antibiotic stewardship programs.
  • Include specific interventions for AMR prevention tailored to the local epidemiological situation in these plans.
  • Share the plans with national, subnational and local IPC committees and incorporate guidance from them.
05
Sustainable capacity
Actions to achieve this level:
  • Provide effective support to healthcare facility IPC programmes nationwide.
  • Ensure that healthcare facilities undertake annual IPCAF and WASH fit assessments as part of their review cycle to address long-term sustainability.
  • Establish a national system for continuous monitoring of progress in fulfilling the IPC core components (i.e. repeat assessments at least annually) and keep track of changes and scores and develop a long-term improvement plan.
  • Analyse and regularly report national IPC and WASH data and support discussions on actions to incorporate lessons learned in the long-term improvement plan.
  • Document the incidence of patient and healthcare worker infections, including M. tuberculosis, and the effectiveness of measures to reduce their occurrence.

Benchmark 3.4:

Optimize use of antimicrobial medicines in human and animal health and agriculture

Objective: To ensure appropriate use of all antimicrobials in human and animal health and agriculture

01
No capacity
  • No or weak policy and regulations on appropriate use, availability and quality of antimicrobials.
02
Limited capacity
Actions to achieve this level:
  • Undertake an assessment of stewardship policies and activities, including regulatory framework and supply chain management of antimicrobials, using a multisectoral approach.
  • Review the essential medicines list and clinical guidelines that promote appropriate use.
  • Assess existing monitoring of antimicrobial use and consumption.
  • Develop a draft national antimicrobial stewardship plan or strategy and national legislation that regulate use, availability and quality of antimicrobials.
03
Developed capacity
Actions to achieve this level:
  • Develop/update and disseminate national stewardship and clinical/treatment guidelines that include the Essential Medicines List AWaRe (Access, Watch, Reserve) categorization for antibiotics promoting appropriate use of antimicrobials.
  • Implement stewardship practices at designated healthcare facilities.
  • Establish SOPs, protocols and databases for monitoring antimicrobial use in humans and animals.
  • Implement antimicrobial stewardship programmes, including monitoring of antimicrobial use, education/communication, and other interventions to improve antibiotic use, at designated facilities.
  • Develop or review the national regulatory framework for appropriate use of antimicrobials in humans.
  • Approve and enact legislation and regulations on import, marketing authorization, production and use of antimicrobials.
04
Demonstrated capacity
Actions to achieve this level:
  • Monitor and evaluate stewardship programmes conducted, including the analysis of antimicrobial use data.
  • Develop and disseminate information, education and communication materials on drug resistance and drug use across both human and animal sectors. These include the use of evidence generated from AMR and antimicrobial use surveillance to inform antibiotic-use practices.
  • Develop a national regulatory framework for appropriate use of affordable, quality assured antimicrobials in humans and animals.
  • Expand antimicrobial stewardship activities to all healthcare facilities.
  • Recommend and implement the phasing out of antimicrobials used as animal growth promotion.
  • Map existing relevant legislation and begin the review process for coherence.
  • Develop and implement legislation on “prescription only” sales of key antibiotics.
05
Sustainable capacity
Actions to achieve this level:
  • Continue to monitor antimicrobial stewardship activities and update the national stewardship plan on a timely basis and publicly report on the results.
  • Track antibiotic dispensing and set national targets for improvement.
  • Measure antibiotic use and assess appropriateness.
  • Monitor antibiotic quality and address drivers of prescribing behaviours.
  • Implement a national regulatory framework for appropriate use of affordable, quality assured antimicrobials in humans and animals.
  • Monitor “prescription only” sales of key antibiotics.
  • Complete the review of relevant legislation and enact amendments to make legislation coherent.

Tools: