title: The challenges and successes of implementing a sustainable antimicrobial resistance surveillance programme in Nepal.
abstract: BACKGROUND
  Antimicrobial resistance (AMR) is a major global public health concern and its surveillance is a fundamental tool for monitoring the development of AMR. In 1998, the Nepalese Ministry of Health (MOH) launched an Infectious Disease (ID) programme. The key components of the programme were to establish a surveillance programme for AMR and to develop awareness among physicians regarding AMR and rational drug usage in Nepal.
  
  
  METHODS
  An AMR surveillance programme was established and implemented by the Nepalese MOH in partnership with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) from 1998 to 2003. From 2004 to 2012, the programme was integrated and maintained as a core activity of the National Public Health Laboratory (NPHL) and resulted in an increased number of participating laboratories and pathogens brought under surveillance. The main strategies were to build national capacity on isolation, identification and AMR testing of bacterial pathogens, establish laboratory networking and an External Quality Assessment (EQA) programme, promote standardised recording and reporting of results, and to ensure timely analysis and dissemination of data for advocacy and national policy adaptations. The programme was initiated by nine participating laboratories performing AMR surveillance on Vibrio cholerae, Shigella spp., Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria gonorrhoeae.
  
  
  RESULTS
  The number of participating laboratories was ultimately increased to 13 and the number of pathogens under surveillance was increased to seven (Salmonella spp. was added to the surveillance programme in 2002 and extended spectrum β-lactamase producing Escherichia coli in 2011). From 1999 to 2012, data were available on 17,103 bacterial isolates. During the AMR programme, we observed changing trends in serovars/species for Salmonella spp., Shigella spp. and V. cholerae and changing AMR trend for all organisms. Notably, N. gonorrhoeae isolates demonstrated increasing resistance to ciprofloxacin. Additionally, the performance of the participating laboratories improved as shown by annual EQA data evaluation.
  
  
  CONCLUSIONS
  This Nepalese AMR programme continues and serves as a model for sustainable surveillance of AMR monitoring in resource limited settings.
authors.forename: Sarala
authors.initials: S
authors.lastname: Malla
authors.forename: Shyam Prakash
authors.initials: SP
authors.lastname: Dumre
authors.forename: Geeta
authors.initials: G
authors.lastname: Shakya
authors.forename: Palpasa
authors.initials: P
authors.lastname: Kansakar
authors.forename: Bhupraj
authors.initials: B
authors.lastname: Rai
authors.forename: Anowar
authors.initials: A
authors.lastname: Hossain
authors.forename: Gopinath Balakrish
authors.initials: GB
authors.lastname: Nair
authors.forename: M John
authors.initials: MJ
authors.lastname: Albert
authors.forename: David
authors.initials: D
authors.lastname: Sack
authors.forename: Stephen
authors.initials: S
authors.lastname: Baker
authors.affiliation: International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. mrahman@oucru.org.
authors.forename: Motiur
authors.initials: M
authors.lastname: Rahman
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D003906:Developing Countries; D024881:Drug Resistance, Bacterial; D004926:Escherichia coli / Q000187:drug effects / Q000302:isolation & purification; D006090:Gram-Negative Bacteria / Q000187:drug effects* / Q000302:isolation & purification; D006094:Gram-Positive Bacteria / Q000187:drug effects* / Q000302:isolation & purification; D006193:Haemophilus influenzae / Q000187:drug effects / Q000302:isolation & purification; D006291:Health Policy; D006801:Humans; D007753:Laboratories; D009344:Neisseria gonorrhoeae / Q000187:drug effects / Q000302:isolation & purification; D009390:Nepal; D015397:Program Evaluation / Q000379:methods* / Q000706:statistics & numerical data; D012107:Research Design; D012475:Salmonella / Q000187:drug effects / Q000302:isolation & purification; D012760:Shigella / Q000187:drug effects / Q000302:isolation & purification; D013296:Streptococcus pneumoniae / Q000187:drug effects / Q000302:isolation & purification; D014734:Vibrio cholerae / Q000187:drug effects / Q000302:isolation & purification; D001618:beta-Lactamases / Q000187:drug effects* / Q000302:isolation & purification
chemical_list: D000900:Anti-Bacterial Agents; D001618:beta-Lactamases