ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance
Authors: Mo Yin , Ding Ying , Cao Yang , Hopkins Jill , Ashley Elizabeth A. , Waithira Naomi , Wannapinij Prapass , Lee Sue J. , Ling Claire L. , Hamers Raph L. , Roberts Tamalee , Lubell Yoel , Karkey Abhilasha , Akech Samuel , Lissauer Samantha , Opintan Japheth , Okeke Iruka , Eremin Sergey , Tornimbene Barbara , Hsu Li Yang , Thwaites Louise , Lam Minh Yen , Pham Ngoc Thach , Pham Tieu Kieu , Teo Jeanette , Kwa Andrea Lay-Hoon , Marimuthu Kalisvar , Ng Oon Tek , Vasoo Shawn , Kitsaran Suwatthiya , Anunnatsiri Siriluck , Kosalaraksa Pope , Chotiprasitsakul Darunee , Santanirand Pitak , Plongla Rongpong , Chua Hock Hin , Tiong Xun Ting , Wong Ke Juin , Ponnampalavanar Sasheela Sri La Sri , Sulaiman Helmi Bin , Mazlan Mohd Zulfakar , Salmuna Zeti Norfidiyati , Rajahram Giri Shan , Zaili Mohd Zaki Bin Mohd , Francis Joshua R. , Sarmento Nevio , Guterres Helio , Oakley Tessa , Yan Jennifer , Tilman Ari , Khalid Muhammad Osama Rehman , Hashmi Madiha , Mahmood Syed Faisal , Dhiloo Azizullah Khan , Fatima Ambreen , Lubis Inke Nadia D. , Wijaya Hendri , Abad Cybele L. , Roman Arthur Dessi , Lazarte Cecilia C. Maramba , Mamun Gazi Md. Salahuddin , Asli Rosmonaliza , Momin Muhd Haziq Fikry bin Haji Abdul , Nyamdavaa Khurelbaatar , Gurjav Ulziijargal , Bory Sotharith , Varghese George M. , Gupta Lalit , Tantia Pratik , Sinto Robert , Doi Yohei , Khanal Basudha , Malijan Greco , Lazaro Jezreel , Gunasekara Samanmalee , Withanage Sumudu , Liu Po Yu , Xiao Yonghong , Wang Minggui , Paterson David L. , Doorn H. Rogier van , Turner Paul 
Published: August 2023

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs).

Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies.

Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest.