Infection Prevention and Control in Combating Antimicrobial Resistance in Sudan

Ghada Omer Shouna1*, Maye Abu Omar2, Samira Hamid Abdelrahman3 and Gamal Khalafalla Mohammed4

Committee; JEE: Joint External Evaluation; IHR: International Health Regulations; IPC: Infection Prevention and Control; KSMoH: Khartoum State Ministry of Health; MOEN: Ministry Of Environment and Natural Resources; MOGE: Ministry Of General Education; WHA: World Health Assembly; WHO: World Health Organization.

Introduction

Antibiotics are valuable therapeutic agents that brought many infectious diseases under control [1, 2]. Today, they are indispensable in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, cancer chemotherapy and even some viral infections would not be possible without access to effective antibiotics [3]. Unfortunately, the imprudent use of these medicines is bringing their miraculous effect to an end and the rapid development of resistance is threatening heath security globally. Antimicrobial resistance (AMR) is increasingly recognised as a key public health concern for both developed and developing countries due to its potentially alarming socioeconomic impact on health [4].

The control of infectious diseases is seriously threatened by the steady increase in the number of microorganisms that are resistant to antimicrobial agents. Resistant infections adversely affect mortality, treatment costs, disease spread, duration of illness, and increase cost to health systems [5, 6]. Although antimicrobial resistance is a natural phenomenon, it is being propagated by misuse of antimicrobial medicines, inadequate or inexistent programmes for infection prevention and control (IPC), poor-quality medicines, weak laboratory capacity, inadequate surveillance and insufficient regulation of the use of antimicrobial medicines [7, 8]. Surveillance of AMR is now one of the components of International Health Regulations (IHR). In 2012, the World Health Assembly (WHA65.23) urged State Parties to take the necessary steps to prepare and carry out appropriate national implementation plans in order to ensure the required strengthening [9], development and maintenance of the core public health capacities as provided for in the IHR [10]. In 2016, a multi-sectoral International Evaluation Team conducted a joint assessment of IHR core capacities of Sudan using the World Health Organization’s (WHO) International Health Regulation (IHR) Joint External Evaluation (JEE) tool [11]. The assessment concluded that capacities for combating AMR scored low. The indicators included antimicrobial resistance detection, surveillance of infections caused by resistant pathogens, healthcare associated infection prevention and control programmes, and antimicrobial stewardship activities [1, 12].

On the other hand, a significant information gap was identified in several areas during a Joint Food and Agricultural Organization-World Organization for Animal Health-World Health Organization (FAO-OIE-WHO) consultation on AMR in Sudan towards developing a national action plan on AMR [13]. It was deemed necessary to gather information for use in developing a national action plan on AMR for Sudan, which led to undertaking a study that was guided by the WHO’s five strategic objectives of Global Action Plan (GAP) on Antimicrobial Resistance (Figure 1) [14].

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This paper focuses on the third objective, i.e. reduction of the incidence of infection through effective sanitation, hygiene and infection prevention measures.

Methods

The study comprised a series of methods, which involved meetings and interviews with key informants from the World Health Organization (WHO) Country Office and other governmental institutions such as health, environment and education among others in Khartoum that play a role in combating AMR, and reviewing the relevant documents available pertaining to the subject of AMR in Sudan. Interviews were conducted with key informants using a questionnaire guide to obtain information about surveillance system to provide data on antimicrobial susceptibility, hygiene, infection prevention and control measures in health facilities and wider community in regard to reducing the incidence of infection through effective sanitation, hygiene and infection prevention. During the interviews, the study explored measures and programmes that were in place to ensure hygiene and infection control in health facilities, and how policies and programmes were monitored and evaluated. Data from key informants was used to supplement and complement information obtained from the documents. The documents reviewed included strategic plans, national and sectoral policy documents and mission reports available at WHO office in Sudan, Federal Ministry of Health (FMoH), Khartoum State Ministry of Health (KSMoH), and Ministry of General Education (MOGE), which were either obtained physically or from various websites [14].

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As illustrated in Figure 2, in order to address objective 3 of GAP, the study considered the availability of a surveillance system to provide data on antimicrobial susceptibility and measures that are in place to promote hygiene and infection control. In this regard, information from the document review and the interviews was collated to identify gaps that need to be addressed in line with the strategic objectives of the WHO GAP on Antimicrobial Resistance.

Discussion and Conclusion

The most serious and difficult-to-treat antibiotic- resistant infections occur in health care facilities, not only because that is where patients with serious infections are treated but also because of the intensive use of antibiotics [20]. Although the development of resistance in such situations may be a natural consequence of necessary antimicrobial use, the study has shown that measures to prevent and control infection that may contribute to the spread of microorganisms resistant to antimicrobial medicines are inadequate in Sudan.

Poor or ineffective measures to promote hygiene and infection prevention in health facilities and the natural environment, in general, are regarded as pathways by which transmission of antibiotic residues to humans might occur and that could contribute to the development of AMR. Antibiotic residues in the environment may originate from wastewater, the soil, manure and other food waste. The accumulation of these compounds in the environment, and the impact of such accumulation on the emergence of antibiotic resistance should not be underrated [21]. Similarly, resistant organisms disseminate from humans to animals, and vice versa, often through various environmental pathways, including foodstuffs, animal wastes, and water sources [22]. The study has shown that there is no system or programme to detect antibiotic residues or to block the drivers and pathways of AMR in the environment. Hygiene, cleanliness and waste disposal systems were found to be poor. Therefore there is a need for appropriate intervention strategies for controlling AMR in the environment to limit the emission of resistant strains of bacteria, and strategies to mitigate the potential transmission of antimicrobial resistance to humans [23]. A well-functioning and efficient waste disposal and wastewater treatment system is mandatory for effective preventive measures and environmental protection from AMR. Water quality measures should not only focus on the presence of microorganisms but should also address the antibiotic concentrations in sewages and treatment plants [24].

Sound hygiene and infection prevention measures can limit the spread of resistant microorganisms and reduce antimicrobial misuse and overuse. Such measures will include hand hygiene, appropriate aseptic techniques, maintenance of clean, hygienic medical equipment along with thoughtful and thorough surveillance, monitoring and evaluation measures [25]. Hand hygiene is now regarded as one of the most important elements of infection control activities. If properly implemented, hand hygiene alone can significantly reduce the risk of cross-transmission of infection in healthcare facilities [26]. Therefore, hygiene and hand washing should be enforced at health facilities. Moreover, it should be a core component of school education to influence behaviour at early age [27].

Data on antimicrobial susceptibility is important for both medical decision-making and policy-making. Unfortunately, the study has shown that, data availability for decision and policy making is limited and remains a challenge in Sudan despite the unprecedented advances in technology over the past several decades. This is most apparent when it comes to empirical and targeted treatment with antibiotics. Years of antibiotic misuse and overuse have led to global resistance and the rise of new bacterial resistance threats that defy treatment with conventional therapies. Antimicrobial susceptibility testing (AST) confirms susceptibility, detects resistance and guides the rational selection of patient therapy. Without solid and reliable data on AST of micro-organisms no rational decisions or actions could be effected to tackle the problem of AMR in the country [28]. Information on local patterns of antimicrobial susceptibility can be collected using AST, so that policies guiding the empiric choice of therapy can be based on data on local resistance trends (also known as the local or institutional antibiogram). AST can also help to identify isolates with defined resistance mechanisms of major interest to infection prevention and control.

A system on data collection, analysis and dissemination is urgently required. The validity and reliability of the data depends on the quality of the medical laboratories, equipment and material used, staff skills and testing techniques. For reliable results, it is suggested to establish an accreditation system for medical laboratories in Sudan. This will ensure the application of standardised techniques and the production of reliable data that can be used for making the necessary medical and policy decisions [29]. Microbiology labs are therefore essential components in stewardship programs to ensure quality specimen collection, appropriate testing, and implementation of rapid diagnostics, AST and data analysis. Recognizing the value of this tool and working collaboratively with laboratories-particularly in high-risk patients is a cornerstone of appropriate and targeted therapy and generation of reliable susceptibility data [30].

In conclusion, the importance of collaboration between the ministries of education, environment and health under the concept of ‘One Health’ need to be promoted. MOEN needs to establish regulatory measures to control the emission of resistant bacteria strain and antimicrobial residues in the environment. Hand washing and other measures for infection control, for example should be a core component of school education to influence children in forming a behaviour that then becomes a habit and eventually a pattern. Similarly, enhancing compliance with the existing guidelines and the development of a roadmap to establish a national AMR surveillance system in Sudan and setting up laboratory- based nationwide surveillance of antimicrobial resistance is essential in order to establish a robust system to tackle the problem of AMR in the country.