![]() ![]() Leapfrogging laboratories: the promise and pitfalls of high-tech solutions for antimicrobial resistance surveillance in low-income settings. Clinical bacteriology in low-resource settings: today’s solutions. National public health institutes are best positioned to provide much-needed governance, coordination and support for the expansion of public health diagnostics and have already shown leadership in multiple contexts. Creative solutions to other infrastructure and supply chain gaps must come from outside biomedicine as well. Next generation, truly appropriate equipment, already on the market for some applications (for example Oxford nanopore sequencers), will require only intermittent power supply. ‘Smart’ machines that can seamlessly resume after a power interruption are those that will feature in the low-resource but fastest-growing diagnostic landscapes of the next decade. Many laboratories have now installed solar back-ups to overcome frequent power supply interruptions. Pandemic-inspired emergency solutions to supply chain failures that plague low-income country health systems and laboratories need to be replaced with robust procurement, shipping and handling, stock management and waste disposal systems. The present promises of molecular diagnostics are a tip of the ice berg, and now is the time to address the hitches that prevent expansion of their use. These and many other examples build a strong case for routine use of molecular diagnostics even in the face of, largely surmountable, challenges 7. Molecular methods can increase pathogen identification in patients with meningitis several-fold, as shown by the examination of archived samples from Bangladesh 6, which trebled the conventional sensitivity and retrospectively uncovered a chikungunya virus outbreak. Culture followed by whole-genome sequencing (WGS) made it possible to simultaneously identify the unusual etiologic agents of neonatal sepsis in hospitals in the Gambia, determine their antimicrobial resistance profiles and pinpoint nosocomial outbreaks 5. In both instances, the advance information provided by on-the-spot PCR testing provided early insights that guided the public health response 3. Unexpected appearance of Ebola and Yellow fever hemorrhagic viruses in Nigeria in the past decade was rapidly detected using molecular methods weeks before more standard reference techniques could be deployed. Success case studies for molecular diagnostic applications in low-income settings extend well beyond COVID-19. Supply chains for pathogen-specific diagnostics are also complex, easily disrupted and difficult to adjust to new pathogens. Serological methods, although typically much faster and simpler, often do not provide the breadth and depth of information needed to make informed and effective decisions, sometimes lack specificity and are not available for many pathogens. The impact of culture-based methods on patient care, infection prevention and control, and outbreak responses is further limited by long turnaround times and challenges in quality assurance. Some pathogens are cheap to culture, whereas culture is costly for others. ![]() However, traditional culture-based clinical microbiology, typically deemed ‘appropriate’, has been notoriously difficult to sustain at the required quality in lowest-income settings without external support 1, 2. Despite their utility and precision, molecular diagnostics were deemed ‘inappropriate’ for decades, as they were considered to be too finicky, contamination-prone, expensive and technically complex to be used where resources are constrained, skills in short supply and infrastructure not up to date. A golden rule for building laboratory capacity in resource-limited settings is selecting techniques that are workable and can be sustained.
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