Clinical bacteriology in low-resource settings: today's solutions

Abstract

Low-resource settings are disproportionately burdened by infectious diseases and antimicrobial resistance. Good quality clinical bacteriology through a well functioning reference laboratory network is necessary for effective resistance control, but low-resource settings face infrastructural, technical, and behavioural challenges in the implementation of clinical bacteriology. In this Personal View, we explore what constitutes successful implementation of clinical bacteriology in low-resource settings and describe a framework for implementation that is suitable for general referral hospitals in low-income and middle-income countries with a moderate infrastructure. Most microbiological techniques and equipment are not developed for the specific needs of such settings. Pending the arrival of a new generation diagnostics for these settings, we suggest focus on improving, adapting, and implementing conventional, culture-based techniques. Priorities in low-resource settings include harmonised, quality assured, and tropicalised equipment, consumables, and techniques, and rationalised bacterial identification and testing for antimicrobial resistance. Diagnostics should be integrated into clinical care and patient management; clinically relevant specimens must be appropriately selected and prioritised. Open-access training materials and information management tools should be developed. Also important is the need for onsite validation and field adoption of diagnostics in low-resource settings, with considerable shortening of the time between development and implementation of diagnostics. We argue that the implementation of clinical bacteriology in low-resource settings improves patient management, provides valuable surveillance for local antibiotic treatment guidelines and national policies, and supports containment of antimicrobial resistance and the prevention and control of hospital-acquired infections.

Non-typhoidal Salmonella bloodstream infections in Kisantu, DR Congo: Emergence of O5-negative Salmonella Typhimurium and extensive drug resistance

“…Secondly, the absence of a dedicated study team may have had an impact on the intensity and quality of blood culture sampling and laboratory work-up. The intensity and quality of blood culture surveillance were further challenged by the well-known technical, logistical an human resource constraints in a low-resource setting [34][35][36]. Thirdly, detailed clinical data were not registered as part of the surveillance.…”

Febrile illness in Asia: gaps in epidemiology, diagnosis and management for informing health policy

“…The provision of equipment for laboratory diagnostics should not be prioritized until human capacity has been enhanced, and systems should be in place for training, sustainable maintenance, and provision of consumables. Training and facilitation of the clinicelaboratory interface to ensure the appropriate interpretation of diagnostic test results for patient management and disease prevention are also key [37]. Many new technologies are being developed for diagnosis but, especially in the face of AMR, we should be optimizing use of current appropriate, inexpensive, and sustainable techniques until new techniques become affordable and human capacity is in place for their use [36].…”

Point-of-care and point-of-‘can’: leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics

“…Healthcare-or community-associated invasive bacterial infection Gram stain, where expertise exists; however not of use for bloodstream infections and prone to many errors [12] Bacterial culture and antimicrobial susceptibility testing [12,19] Implementation of quality-assured basic techniques is lacking in most LRS reference laboratories and should be prioritized [12,19] At the primary level: biomarker and digitally assisted decision tools to distinguish bacterial from non-bacterial fevers [8] and/or multi-disease detection platforms [64] At the secondary levelþ: simplified approaches to classic bacteriology techniques [12], new tools for rapid phenotypic determination of AST NAAT and MALDI-TOF-based AST face significant challenges because of the wide array and changeability of mechanisms of resistance Dengue…”

“…Combination RDTs that detect both IgM/IgG and the NS1 antigen [65]. Able to diagnose dengue at different points in time after initiation of symptoms Commercial availability and production history of RDT has been inconsistent since its introduction At the primary level: biomarker and digitally assisted decision tools to distinguish bacterial from non-bacterial fevers [8] and/or multi-disease detection platforms [64] At the secondary levelþ: simplified approaches to classic bacteriology techniques [12,50] resource settings may play in the near future, and how they can interact with end-users and NMFI patients ( Fig. 1).…”

“…Although not yet widely deployed in clinical microbiology practice, recent engineering efforts have yielded equipment adapted to the environmental challenges of low-resource settings, such as solar-powered autoclaves and electricity-free incubators [12]. Likewise, several innovations developed for the vaccine sector present solutions for maintaining specimen stability during shipment, such as small low-temperature refrigerators and freezers, and custom-made affordable temperature-monitoring devices [53].…”