RESUMO
BACKGROUND: Local and global surveillance of antibiotic resistance (ABR) has proven a challenge to implement effectively in low- and middleincome (LMI) settings. Environmental surveillance solutions are increasingly highlighted as a strategy to help overcome such problems, and thus to promote global health as well as the local management of ABR in LMI countries. While technical and scientific aspects of such solutions are being probed continuously, no study has investigated their practical feasibility. OBJECTIVE: Explore practical barriers for environmental surveillance of ABR in LMI countries, and pathways for surveillance experts to manage these. METHODS: To start charting this unknown territory, we conducted an explorative, qualitative interview study with key informants, applying a constructivist grounded theory approach to analyze the results. RESULTS: Barriers were identified across infrastructural, institutional and social dimensions, and pathways to manage them were mostly counterproductive from an ABR management perspective, including avoiding entire regions, applying substandard methods and failing to include local collaborators. CONCLUSION: The research community as well as international agencies, organizations and states have key roles and responsibilities for improving the prospects of feasible environmental ABR surveillance in LMI-settings.
Main result: Physical infrastructural, institutional and socio-cultural barriers to environmental antibiotic resistance surveillance in low- and middle-income countries contribute to global health injustices as well as ineffective global antibiotic resistance management, while surveillance experts report pathways to manage these barriers which tend to worsen these negative effects. Added value: This seminal study is the first to probe this area, and thus provides unique new insights for further research and improved practices, as well as practical suggestions for research and policy to this effect. Practical implications: As environmental strategies are main candidates to avoid known problems to achieve effective antibiotic resistance surveillance in low- and middle income-settings, causing major gaps in global health surveillance as well as problems to clinically manage resistant infections in local health systems, it is important that the implementation of environmental surveillance strategies are optimal and avoid counterproductive measures to overcome obstacles.