National Programme on AMR Containment

National Programme on AMR Containment

Antimicrobial resistance (AMR) is a growing public health problem. Resistance has emerged even to newer & more potent antimicrobial agents like Carbapenems. The rapid spread of multi-drug resistant bacteria and the lack of new antibiotics to treat infections caused by these organisms pose a rapidly increasing threat to human health which urgently needs to be tackled to prevent untreatable illness from becoming a reality.

India has given due cognizance to the problem of Antimicrobial resistance and to tackle this issue, Government of India launched the “National Programme on AMR Containment” during the 12^th five-year plan in the year 2013. The programme is being coordinated by the Centre for Bacterial Diseases and Drug Resistance, NCDC.

The current objectives of this programme are: 

1. Establish a laboratory-based AMR surveillance system in the country to generate quality data on antimicrobial resistance

2. To strengthen infection control practices and establish surveillance of Healthcare associated infections
3. To conduct surveillance of antimicrobial usage in different health care settings & promote rational use of Antimicrobials through Antimicrobial stewardship practices
4. To generate awareness amongst health care providers and community for AMR and rational use of antimicrobials.

Activities carried out under the programme:

1. AMR Surveillance

Under the programme, National AMR Surveillance network (NARS-Net) has been established to determine the magnitude and trends of AMR in different geographical regions of the country. The network labs, which include government medical colleges, are supported for capacity building under NARS-Net and are required to submit AMR surveillance data of seven priority bacterial pathogens of public health importance:   Staphylococcus aureus, Enterococcus spp., Klebsiella spp., Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii/ Acinetobacter calcoaceticus complex, Salmonella enterica serotypes Typhi and Paratyphi. Since the year 2020-21, AMR Surveillance has been expanded to include Candida spp, from bloodstream infections. Two more bacterial pathogens have been included in the priority pathogens list for AMR surveillance in 2023 namely Shigella species and Vibrio cholerae.

National AMR Surveillance Network (NARS-Net):

A. National Reference labs (NRLs): Two NRLs have been established under the programme. One NRL is for bacterial pathogens established at the Centre for Bacterial Diseases and Drug Resistance which conducts EQAS for programme sites. This lab also conducts confirmation of AMR alerts submitted by the programme sites. The second NRL under the programme is for fungal pathogens established at the Fungal laboratory of Vallabhbhai Patel Chest Institute, Delhi.

B. Sentinel AMR Surveillance sites: The programme is supporting the state medical colleges for strengthening AMR detection and containment. Currently the programme includes following 40 labs in 31 states/UTs:

1. BJ Medical College, Ahmedabad, Gujarat
2. BJ Medical College Pune, Maharashtra
3. Medical College and Hospital, Chandigarh
4. GSVM Medical college Kanpur, UP
5. Lady Hardinge Medical College, Delhi
6. Mysore Medical College & RI Mysore, Karnataka
7. SMS Medical College Jaipur, Rajasthan
8. VMMC and associated Safdarjung Hospital, Delhi
9. Government Medical College, Thiruvananthapuram, Kerala
10. KAPV Government Medical College, Tiruchirappalli, Tamil Nadu
11. Gauhati Medical College and Hospital, Guwahati, Assam
12. NEIGRIHMS, Shillong, Meghalaya
13. Mahatma Gandhi Memorial Medical College, Indore, MP
14. Indira Gandhi Medical College, Shimla, HP
15. Government Medical College, Aurangabad, Maharashtra
16. Osmania Medical College and General Hospital, Hyderabad, Telangana
17. Guntur Medical College & Govt. General Hospital, Andhra Pradesh
18. Agartala Govt. Medical College & GBP Hospital, Agartala, Tripura
19. SCB Medical College Hospital, Cuttack, Odisha
20. Government Medical College, Jammu, J&K
21. B D Sharma PGIMS Rohtak, Haryana
22. Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
23. Indira Gandhi Institute of Medical Sciences, Patna, Bihar
24. Government Medical College, Haldwani, Uttarakhand
25. Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh
26. Gandhi Medical College, Bhopal, Madhya Pradesh
27. Calcutta School of Tropical Medicine, Kolkata, West Bengal
28. GMERS Medical College and Hospital, Valsad, Gujarat
29. LLRM Govt. Medical College, Meerut, Uttar Pradesh
30. Coimbatore Medical College & Hospital, Coimbatore, Tamil Nadu
31. Maulana Azad Medical College & Associated Hospital, Delhi
32. Sardar Patel Medical College and Hospital, Bikaner, Rajasthan
33. Karnataka Institute of Medical Sciences, Hubbali, Karnataka
34. Indira Gandhi Medical College & Research Institute, Puducherry
35. NAMO Medical College & Research Institute, Silvassa, UT of Dadra & Nagar Haveli and Daman & Diu
36. Goa Medical College and Hospital, Goa
37. STNM Hospital, Gangtok, Sikkim
38. Government Medical College, Patiala, Punjab
39. Zoram Medical College, Mizoram
40. Andaman and Nicobar Institute of Medical Sciences, Port Blair

C. AMR surveillance data is submitted by the network labs to NCDC using the WHONET software on a monthly basis. WHONET data entry and reporting SoP is available at https://ncdc.mohfw.gov.in/showfile.php?lid=955. Feedback is provided to the labs by NCDC regarding completeness of data and adherence to programme SoP. The corrected data received at  NCDC is analysed and compiled in the form of an annual report. The annual reports of last 5 years data (from 2017-2021) are available on NCDC website at: https://ncdc.gov.in/index1.php?lang=1&level=2&sublinkid=393&lid=349. The National AMR surveillance data is also uploaded annually onto GLASS (Global AMR Surveillance system).

D. Confirmation of emerging AMR alerts: Network sites are mandated to submit emerging AMR alerts as defined under the programme. The duly filled alert form is to be submitted with the strains. The form is available : https://ncdc.mohfw.gov.in/showfile.php?lid=957. 

E. External Quality Assessment Scheme: The quality of data submitted under the National AMR surveillance network is ensured through External Quality Assessment Scheme (EQAS) conducted by NCDC, under which all network sites submit isolates every quarter (as per programme guidelines) to the National Reference Laboratory established at NCDC. The AMR surveillance network sites are also mandated to submit AMR alert strains for confirmation to NRL at NCDC as and when isolated. The labs under the programme are also required to enrol onto the IAMM EQAS programme.

F. Development of SOPs: To standardise the lab testing and data being collected across the network sites under the programme, SOPs have been developed which are updated on regular basis. The SOPs are listed below and are available at https://ncdc.mohfw.gov.in/index1.php?lang=1&level=2&sublinkid=785&lid=578:

1. AMR Surveillance in Priority Bacterial Pathogens under NARS-Net
   • Broth microdilution colistin susceptibility test for aerobic Gram-negative bacteria
   • Broth microdilution (BMD) vancomycin susceptibility test for aerobic Gram-positive cocci
   • Colistin agar test for colistin resistance for Enterobacterales and Pseudomonas aeruginosa 
   • Vancomycin agar screen test for Staphylococcus aureus and Enterococcus species
   • Internal Quality Control for disk diffusion AST
   • Preservation of bacterial isolates/control strains
   • Submission of AMR Surveillance EQAS isolates and reporting emerging AMR Alerts
2. WHONET data entry and reporting

• Facility level Antibiogram development tools
• Alert form for submitting AMR emerging Alerts

Trainings & workshops:

1. All network site laboratories are provided training on the standardised procedures as per the SoPs.
   • WHONET software for data management
   • Using the WHONET data for developing antibiograms at facility level using antibiogram development tools prepared under the programme. The links for the tools for development of facility level antibiogram is at https://ncdc.mohfw.gov.in/showfile.php?lid=956.
   • Broth microdilution testing for colistin and vancomycin.
   • Agar dilution method for colistin AST

2. Since year 2020, trainings have been initiated using the virtual platform (iECHO platform) in collaboration with CDC, ASM and ECHO-India for bacterial identification using conventional methods. Faculty from NCDC and networks sites also take sessions in this virtual training programme.

Committee of experts:

A committee of experts has been constituted for technical guidance to the programme. The members of the committee are senior faculty from some of the network sites. This committee has developed the lab testing modules for bacterial identification of AMR Surveillance priority pathogens including biochemical algorithms

Onsite support visits & review meetings: Onsite support visits are done by AMR programme unit officers for hand holding the sites in implementation of programme activities. Annual Review meetings are conducted to review the status and site-wise progress of the network labs under the programme.

2. National Treatment Guidelines:

National Treatment Guidelines for antimicrobial use in infectious diseases has been released and uploaded on the website at: https://ncdc.gov.in/WriteReadData/l892s/File622.pdf. It is to serve as a guide for the hospitals/clinics to formulate their own local antibiotic policy.  

3. Infection Prevention & Control guidelines and surveillance of healthcare associated infections:

“National Guidelines for Infection Prevention and Control in Healthcare facilities” has been developed with support from WHO and have been disseminated to various stakeholders and also unloaded on NCDC website at https://ncdc.gov.in/showfile.php?lid=431. These guidelines have been translated into training modules which have been used for conducting Training of trainers for 31 states. The training modules are available at 

The programme has recently initiated the surveillance of healthcare associated infections for which it is coordinating with the ICMR-AIIMS HAI surveillance project for technical support including trainings, SoPs, guidelines and other technical material and the surveillance portal for submission of HAI surveillance data by the programme sites. For technical details refer to ICMR-AIIMS HAI surveillance network website: https://www.haisindia.com

4. IEC Activities:

Media material for IEC has been developed on judicious use of antibiotics and prevention of infections including hand hygiene and is made available on NCDC website. Communications are sent to states every year to conduct IEC activities during the World Antibiotic Awareness Week (WAAW) celebrated in the month November. The reports received from various states and Institutions are compiled and uploaded on website.

5. Support Establishment of State AMR Surveillance Network

Under the programme since 2022-23, State AMR Surveillance Networks are being established in a phased manner.  Since 2022-23, 6 state medical colleges under NARS-Net have been supported to establish the state level networks in their respective states. The nodal centres in coordination with NCDC are to conduct sensitization meetings, lab and data management trainings and review meetings for state network laboratories (government medical colleges and large private institutions).