The World Health Organization has recently urged all countries to prioritize antimicrobial resistance surveillance for selected organisms including carbapenem-resistant Enterobacterales (CRE).
We conducted a mixed-methods cross-sectional study with both quantitative and qualitative components using GERMS-SA enhanced CRE national surveillance at four sentinel sites in Gauteng Province (Steve Biko academic, Charlotte Maxeke Johannesburg Academic Hospital, Chris Hani Baragwanath, and Dr. George Mukhari), South Africa, from 1 January 2019 to 31 December 2020.
A case was defined as any person from whom Enterobacterales was isolated from blood culture and was resistant to ertapenem or any other carbapenem if ertapenem susceptibility testing was not done (doripenem, imipenem, meropenem). Laboratory-based surveillance for CRE from bloodstream infections was performed at the National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses (CHARM), South Africa.
Sentinel laboratories submitted case report forms together with isolates to CHARM for phenotypic and genotypic characterization, as well as antimicrobial susceptibility testing. A surveillance audit comprising demographic and laboratory characteristics was conducted using data extracted from the National Institute for Communicable Diseases surveillance data warehouse. CRE bloodstream infection cases were described epidemiologically and surveillance attributes pertaining to simplicity, acceptability, usefulness, and timeliness were evaluated.
Qualitative data were collected through a Google Forms online survey, distributed to participants by email. During this surveillance evaluation, a total of 1 266 case-patients was detected from the four enhanced sentinel sites. The median age of the cases was 35 years (Interquartile range (IQR), 17–52 years) and males accounted for 53% (n=673). Among CRE case patients, outcomes were known for 64% (n=810) and 38% (310/810) were known to have died. Of the total cases, 43% (n=556/1 265) were audit (only demographic and laboratory data, no isolates sent to CHARM). CHARM received 709 isolates from the sentinel laboratories. Of those, 86% (609/709) were viable and tested positive for genes present in carbapenemase-producing Enterobacterales. Online questionnaires were distributed to forty surveillance system stakeholders, of which 65% (n=26) consented to participate. Ninety-two percent (22/24) of participants reported that the role they played in this CRE surveillance system was their responsibility and 63% (15/24) of those reported that their roles did not require a lot of effort.
The system evaluation reported longer durations between the steps of the surveillance system; the median time taken from CRE diagnosis to receipt of specimen at the surveillance laboratory was 9 days (IQR 5–14 days), and the median time from when isolates were received by the surveillance laboratory to phenotypic characterization was 15 days (IQR 7–53 days). About 76% (19/25) were not aware of the purpose of the data collected by the CRE surveillance system and 50% (13/26) reported never receiving any feedback on data collected by the surveillance system. The suboptimal survey response rate and participants not knowing about surveillance reports suggest that the GERMS—SA surveillance system was not operating as effectively. To improve usefulness, the GERMS-SA CRE surveillance implementers should facilitate ongoing training and non-electronic dissemination of surveillance findings to stakeholders.
