Strengthening antimicrobial resistance surveillance in Italy: proposal for an early warning system and performance evaluation

An urgent need of implementing national surveillance systems for timely detection and reporting of emerging antimicrobial resistance (AMR) has been advocated by the World Health Organization (WHO). However, public information on existing national early warning systems (EWSs) for new or unusual profiles of AMR is often incomplete, and a comprehensive overview on this topic is currently lacking. In Italy, national AMR surveillance systems provide epidemiological reports on annual basis and an EWS to timely detect the spread of emerging profiles of AMR is currently not available. Furthermore, since the Italian healthcare system is a Beveridge-like model characterized by a high degree of decentralization, with 21 different regional health systems, microbiological alert systems existence at subnational (regional) level was unclear. The research project aimed to identify, through evidence collection at different levels, the key elements needed to develop an effective national EWS, capable of allowing timely data sharing between national and subnational levels, ensuring data accessibility to different stakeholders and preventing the spread of microorganisms that may threaten public health, also at international level. To this end, three main research activities have been carried out: i) evidence collection on EWSs for emerging AMR available at international level, focusing on high-income countries, through a systematic review of literature; ii) in-depth analysis at subnational level in Italy, through a web-based survey addressed to AMR regional representatives, in order to map and describe existing regional EWSs; iii) in-depth analysis at national level in Italy, through the evaluation of one of the most relevant national AMR surveillance systems, i.e. the Carbapenem Resistant Enterobacterales bloodstream infections surveillance system (CRE). The research findings allowed the elaboration of an evidence-based proposal for a national web-based alert and early reporting system that focus on emerging profiles of antimicrobial resistance.