# A Six-Step Protocol for Monitoring Antimicrobial Resistance Trends Using WHONET and R: Real-World Application and R Code Integration

## TL;DR

This paper introduces a six-step protocol using WHONET and R to monitor antimicrobial resistance trends, with real-world data and code examples.

## Contribution

The novel contribution is a standardized, reproducible workflow integrating WHONET and R for AMR trend analysis.

## Key findings

- WHONET and R can be combined for effective AMR surveillance.
- Real-world data from an Italian hospital demonstrates the protocol's applicability.
- The workflow enables rapid and standardized AMR trend analysis.

## Abstract

Antimicrobial resistance is a global health issue, and the WHO has made significant efforts in the development of tools for its monitoring. However, such tools are underutilized, due to limited knowledge, technical capacity, and scarcity of economic resources. AMR surveillance can be conducted using WHOnet and R, two free-of-charge software tools widely adopted in both clinical practice and scientific research. WHOnet is designed for managing laboratory data and antimicrobial susceptibility test results, while R is a programming language dedicated to statistical computing and data visualization. The combined use of these tools enables a reproducible workflow for retrospective AMR trend analysis. This paper provides step-by-step instructions on how to perform such analysis and also provides the respective R code. The described code and software results are shown using real-world data from an Italian hospital as an example. The standardization of the analysis process and the rapid availability of data on antimicrobial resistance are critical for both clinicians and public health professionals. They would allow for empirical decisions on antimicrobial treatment based on the specific epidemiological characteristics of the hospital or community setting.