Annex 1
Important points noted in the responses of Eastern Mediterranean Region countries to a questionnaire on antimocrobial resistance
The authors reviewed the responses to the questionnaire which was sent by the Quality and Care and Health Technology Unit to focal point laboratories. Out of 18 countries that nominated focal point laboratories, 16 responded to the questionnaire. The following points were noted:
Six national focal point laboratories are not affiliated to the WHO External Quality Assessment Scheme (EQAS). These are Cyprus, the Libyan Arab Jamahiriya, Pakistan, Sudan, the Syrian Arab Republic, and the Republic of Yemen. Morocco and Oman are affiliated to other EQAS systems.
In most countries there is no national information network on antimicrobial resistance of infectious agents. However, in a few countries some data have been collected on specific problems (enteric and/or nosocomial pathogens). Some data on antimicrobial resistance have been made available in Bahrain, Jordan, Morocco, Oman, and the United Arab Emirates.
It is not clear whether in most countries the national reference laboratories function with reliable terms of reference.
WHO treatment guidelines are followed for acute respiratory infections, diarrhoeal diseases, and sexually transmitted diseases in most countries which responded to the questionnaire (except Iraq and Sudan). However, based on responses to the questionnaire, it is not clear whether these guidelines are used in Egypt, the Islamic Republic of Iran, Jordan, and Oman.
According to the responses to the questionnaire, antibiotics could be obtained without prescription in Egypt, Iraq, Pakistan, Qatar, Sudan, Tunisia, and the Republic of Yemen.
The information provided on antibiotic prescribing policies and on susceptibility testing methods in the respective countries will be very useful in the formulation of guidelines for a practical and realistic surveillance programme.
Several persons rightly suggested that the list of nosocomial organisms should also include Pseudomonas aeruginosa and Enterobacter spp. Further additions are Providencia spp and Serratia marcescens.
The following are the working group's critical comments to the questionnaire responses.
Laboratories should use the generic rather than the commercial names of antimicrobials, e.g. cefamandole (not Mandol), cefotaxime (not Claforan).
A distinction should be made between isolates of Haemophilus influenzae from the respiratory tract and from invasive infections (blood, cerebrospinal fluid), the latter generally belonging to capsular type B. It is not relevant to monitor resistance in other species of Haemophilus (parainfluenzae). Erythromycin (nor any other macrolide) should not be used in tests for Haemophilus. The most important test for Haemophilus is a rapid test for b-lactamase (nitrocefin).
Moraxella catarrhalis should be included in the surveillance, being a significant respiratory pathogen with a high prevalence of b-lactamase positives.
Neisseria meningitidis should not be included. Penicillin resistance is not yet a serious problem and there is no simple disc test for accurate detection. Such a test will probably become available in the near future.
Monitoring resistance of Streptococcus pyogenes (group A) has a low priority, except for erythromycin. Testing for penicillin, ampicillin, cephalosporins, or chloramphenicol makes no sense.
Antibiotics should not be tested when they are not clinically effective, e.g. furazolidone for Shigella, erythromycin for Enterobacteriaceae, cephalothin for Vibrio cholerae.
Never duplicate tests for antibiotics having similar activity, e.g. ampicillin and penicillin for pneumococci; ofloxacin and ciprofloxacin for Salmonella typhi; and amoxycillin and ampicillin.
Do not test cephalosporins for Staphylococcus. Oxacillin- or methicillin-resistant staphylococci are clinically resistant against all b-lactams including combinations with inhibitors.
Rare bacterial species should not be monitored, e.g. Flavobacterium spp.
Streptomycin should no longer be tested (with the exception of mycobacteria).
When a result is completely unexpected, it should be repeated or the isolate submitted to a reference laboratory, e.g. ampicillin-resistant S.pyogenes.
The few focal point laboratories which continue to use the Stokes method are encouraged to shift to use the method recommended by the NCCLS. The majority use the Kirby-Bauer method with the NCCLS breakpoints.
An effort should be made to include larger numbers of fastidious organisms such as gonococci and respiratory pathogens.
It is irrelevant to monitor antimicrobial resistance of "diarrhoeagenic" Escherichia coli. Treatment with antibiotics is not recommended (except for the rare enteroinvasive serotypes) and even contraindicated (for the enterohaemorrhagic E.coli).