African Society for Laboratory Medicine (ASLM) presents a Kenyan report on Antimicrobial Resistance (AMR) at a conference in Nairobi

African Society For Laboratory Medicine in conjunction with African CDC and African Union is holding a three day Antimicrobial Resistance(AMR) workshop at the Park Inn by Radisson Hotel in Westlands, Nairobi.

The consultative meeting under the United Kingdom aid Fleming fund regional grant, has 17 countries participating, with 14 from Africa and 3 from Asia.

Present at the conference are stakeholders, subject experts, and technical partners from Member States, International partners, Africa CDC Regional Collaborating Centres (RCCs), and other technical partners.

Conducted under the theme:From data to action, Utilizing the power of data and One Health approaches to tackle AMR together, it encapsulates the need and urgency to now use the data and the lessons learnt to reshape our strategies and approaches for more effective interventions to tackle AMR.

During these three days countries, regional and global stakeholders, funders and partners will be gathering, debating and reaching consensus to take stocks of the achievements and discuss the way forward in alignment with the Africa CDC’s Framework for AMR Control, 2018-2023 and other key global and regional AMR containment initiatives.

Making opening remarks ASLM CEO – Mr. Nqobile Ndlovu referred to Antimicrobial resistance as a “silent pandemic”. Ndolvu shared that According to recent statistics, resistant diseases cause an estimated 700,000 deaths annually, with Africa bearing a disproportionately large share of morbidity and mortality. ” The impact to us, socially and economically cannot be underestimated, highlighting the urgent need to accelerate our actions to contain AMR across our continent and beyond” He added.

Present at the event was Emmanuel Tanui AMR country Director for Human Health Kenya ‘’We need to collaborate together in the different sectors and countries sharing such experiences on how we can effectively control the spread of AMR.

The country has benefited tremendously from the support of Fleming fund through strengthening of AMR surveillance. Case in point, improving quality assurance through provision of proficiency test panels, training and mentorship of health workers, generation of data for policy making and so on. We have also improved our capacity for monitoring consumption and use of antimicrobials through the Monitoring Antimicrobial Resistance and Antimicrobial Use Partnership Project. The data generated has improved decision making, review of policies and guidelines”.

During the event a Kenyan report was presented by the Mapping Antimicrobial resistance and Antimicrobial use Partnership (MAAP) consortium. The report summarises the activities undertaken by the MAAP consortium to implement the Regional Grant and aims to determine national AMR, AMC and AMU surveillance capacity, rates and trends and to assess the antimicrobial flow in Kenya during 2016- 2018.

Kenya had approximately 1037 laboratories in the national laboratory network during the study period, of which 64 reported capacity for bacteriology testing. Self-reports for functioning and quality compliance from 56 laboratories were assessed to determine AMR surveillance preparedness.

The reported AMR rates are based on the analysis of antimicrobial susceptibility results 0f 16 027 positive cultures obtained from 16 laboratories. High levels of resistance were noted for third-generation cephalosporins in the Enterobacterales (67-73%), carbapenem in Pseudomonas aeruginosa (36-51%) and methicillin in Staphylococcus aureus (40-52%). Antimicrobial-resistant infections were found to be more common in males and the elderly. All results should be interpreted cautiously because the participating laboratories were at different service levels and thus had varying testing capacities.

AMC is measured as the number of antimicrobials sold or dispensed, whereas AMU reviews whether antimicrobials are used appropriately based on additional data such as clinical indicators. Only AMC data were retrieved, but AMU data were not obtained due to the lack of a unique patient identifier and tracking systems across hospital departments.

The average national total AMC consumption levels in Kenya between 2016-2018 were 8.8 defined daily doses (DDD) per 1 000 inhabitants per day (DID), ranging from 11 in 2016, 7.4 in 2017 and 8.1 in 2018. Antimicrobial utilisation by the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) classification was highest for penicillins with extended-spectrum (range 21.2% to 29.9%), followed by combinations of penicillins and beta-lactamase inhibitors (range 9.7% to 16.2%) and by combinations of sulfonamides and trimethoprim, including derivatives (range 7.7% to 16.4%).

The top five most consumed antimicrobials were

Amoxicillin,sulfamethoxazole/trimethoprim, ampicillin/cloxacillin, erythromycin and doxycycline. Together they accounted for > 58% of the total consumption share, suggesting a lack of variation. This consumption trend could potentially increase AMR.

The AMC included antimicrobials from the ‘Access’ 70.4%, ‘Watch’ 29.6%, and ‘Reserve’ <0.1% categories. Between 2016-2018, the use of ‘Access’ category antibiotics exceeded the WHO minimum recommended consumption threshold of 60%.

Nine combinations of two or more broad-spectrum fixed-dose combinations of antimicrobials were identified that were not recommended for clinical utility but were nevertheless consumed in Kenya. Of these FDCs, ampicillin/cloxacillin was most commonly consumed (mean DID of 0.7).

Drug resistance index (DRI) is a simple metric based on aggregate rates of resistance measured on a scale of 0-100, where 0 indicates fully susceptible while 100 indicates fully resistant. The DRI estimate was found to be moderately high at 56.2% (95% CI, 42.1–70.3%), implying low antibiotic effectiveness that threatens the effective management of infectious disease and calls for urgent policy intervention. The DRI estimate of Kenya suggests the need for inter-departmental collaborations, increased community awareness and improved stewardship practices to control AMR.

Recommendations made

Policymakers and healthcare providers should note the following recommendations to strengthen AMR and AMC surveillance further to mitigate AMR in Kenya.

• To strengthen the delivery of services by the laboratories, we recommend that all laboratories are mapped across a range of indicators, including population coverage, infectious disease burden, testing capabilities, and quality compliance. This mapping exposes unmet needs and informs the laboratory network expansion plan

• Staff training on laboratory standards, common pathogens identification, and data management skills are essential for high- quality microbiology testing and reporting. Staff capacity building may be achieved by leveraging in-house expertise or outsourcing to external organisations or tertiary facilities

• Curating the correct data and generating evidence is essential to strengthening AMR surveillance. We recommend data collection through standardised formats at all levels (laboratories, clinics and pharmacies) and data analysis automation. We also recommend establishing a system of assigning permanent identification numbers for tracking patients

• Due to the limited number of facilities assessed, the MAAP consortium, per the WHO facility AMU assessment guide, recommends that future AMU and AMC surveillance attempts in the country be conducted through large-scale point prevalence surveys to give a nationally representative portrait of antimicrobials use in Kenya

• The consortium recommends that a comprehensive routine AMC data surveillance policy be developed. The policy should, at the minimum, stipulate AMC data reporting variables and routine data cleaning and reporting practices to minimise the time spent standardising and cleaning data before routine surveillance exercises

• To make future AMC surveillance more time and cost-efficient. Hospitals could consider switching to electronic systems and ensure such systems have capabilities to transfer data across systems and or produce user-friendly reports on AMC

• The consortium recommends that the country’s Antimicrobial Resistance Coordinating Committee (AMRCC) consider introducing facility-level Antimicrobial Stewardship Programmes (ASPs) to regulate the use of broader spectrum antibiotics and educate prescribers on the importance of reserving these to maintain efficacy

• From the assessment, the top five antibiotics consumed within the ‘Access’ and ‘Watch’ categories were the majority of antibiotics consumed in each category. Such a consumption pattern could be postulated to be sub-optimal as evolutionary pressure driving resistance would be focused only on the narrow-band antibiotics consumed. The consortium, therefore, recommends that the country’s ASP explores ways to ensure a wider spread in the consumption of antibiotics within each WHO Access, Watch, and Reserve (AWaRe) category

• The consortium recommends that an urgent survey be conducted by the Ministry of Health (MoH) and AMRCC to assess the availability of the ‘Reserve’ category antibiotics in the country. This survey may inform the subsequent review of the country’s essential medicines list (EML) and treatment guidelines to include these vital antibiotics, if necessary. This approach will ensure that the most vital antibiotics are available for all patients

• National stewardship programmes led by the AMRCC could conduct educational campaigns to inform healthcare practitioners