Antibiotic Resistance: Situation Analysis and Needs Assessment
in Uganda and Zambia (AR-SANA)
Capacity building for laboratory strengthening and
detecting antibiotic resistance: findings of a needs
assessment in Uganda and Zambia
Alliance for the Prudent Use of Antibiotics
1
AMR in Zambia: Key Findings
 S. pneumoniae resistance rates to penicillin rose from 14.3% resistance in 1990s to
53-67 % in 2007.
 Infants are most likely to have S. pneumoniae identified from their blood and spinal
fluid .
 Co-trimoxazole resistance of S. pneumoniae is high (80-100%).
 Enteric infections that affected Zambian children were due to rotavirus and enteric
bacteria (E. coli, V. cholerae, Salmonella spp., and Shigella spp.).
 Available data showed very high resistance among enteric bacteria to gentamicin,
cefotaxime, nalidixic acid, ciprofloxacin, co-trimoxazole and cephalexin ranges
between 70-100%.
Alliance for the Prudent Use of Antibiotics
Antibiotic resistance by drug and selected
pathogens in Zambia
100
90
80
70
Resistance Rate %
Shigella
60
S. Pneumoniae
50
H. Influenzae
40
30
20
10
0
Chloramphenicol
Cotrimoxazole
Antibiotic
Ampicillin
Nalidixic Acid
3
Mortality from severe S. pneumoniae pneumonia of children
in the University Teaching Hospital, Zambia, 2005-2007
800
700
600
Number
500
400
300
200
100
0
admissions
deaths
<1
740
224
1-2
148
23
3-5
147
22
Older
87
6
4
AMR in Uganda: Key Findings
 Acute respiratory and enteric infections in Uganda are main causes of
increased morbidity, mortality and costs.
 Streptococcus pneumoniae, and Haemophilus influenzae type b (Hib)
continue to be the main bacteria responsible for Acute Respiratory Infections
(ARI). Viral etiology (mainly Respiratory Syncytial Virus-RSV) in severe
pneumonia among infants and children needs to be investigated.
 Empirical treatment should be guided by data provided by antibiotic
resistance surveillance, particularly in common pathogens.
 Available information on Antibiotic Resistance (ABR) is in most cases
scattered, incomplete and often unreliable.
Alliance for the Prudent Use of Antibiotics
Antibiotic resistance profiles of S. pneumoniae from 2005- 2007 in
Kampala
120
2005
Resistance Frequency
100
2006
2007
2008
80
60
40
20
Antibiotic
Data from Mulago Hospital Laboratory Data
Alliance for the Prudent Use of Antibiotics
Gentamycin
Chloramphenicol
Erythromycin
Ceftriaxone
Ceftazidime
Ciprofloxacin
Penicillin
Co-trimoxazole
Ampicillin
0
Purpose of the laboratory survey
To examine:
I.
Laboratory capacity to conduct research on antibiotic resistance.
II. Ability of laboratories to deliver accurate results
III. Ability of laboratories to detect pathogens and perform antimicrobial
sensitivity testing
IV. Availability of a system for quality control in the laboratories
V. Availability of mechanisms for dissemination of laboratory/ surveillance data
VI. Availability of a system for collection, analysis and transmission of the data to
be used for antibiotic management decisions
VII. Economic situation of the survey laboratories
VIII. Availability of the WHONET software for antimicrobial resistance
surveillance
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Method of laboratory survey
 17 and 29 laboratories across Zambia and Uganda were surveyed




respectively.
Structured questionnaires (adapted from the WHO assessment
form) were used to conduct the interview.
Training of data collectors was carried out
The survey was carried out 2009 and 2010.
The study obtained ethical approvals from the University of
Zambia Ethical Review Board, the Ethical Review Committee of
Makerere University College of Health Sciences, Kampala, and
Boston Tufts University Institutional Review Board
8
17 Laboratories Surveyed in Zambia
Kasama, Mpika
Mansa
Ndola, Kitwe, Tropical Dis. ,
Nchanga, Arthur Davidson
Lundazi
Maina Soko, Lusaka
Trust, Chest
Disease, UTH
Monze, Livingstone,
Chikankata, Mutendere
9
29 Surveyed Laboratories in Uganda
Alliance for the Prudent Use of Antibiotics
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Laboratory survey Components
I. Laboratory staffing and trainings
II. Laboratory equipment
III. Laboratory supply logistics
IV. Laboratory record keeping for supplies management
V. Sources of laboratory reagents
VI. Specimen collection, handling and labelling
VII. Laboratory specific capacity
VIII.Structure of reporting laboratory results
IX. Quality control procedures
X. Cost of laboratory testing and sources of funding
11
Microbiology Laboratory
University Teaching Hospital of Lusaka
12
Microbiology Laboratory
University Teaching Hospital of Lusaka
Uganda: Sources and supply of bacteriological
laboratory consumables
Source of reagents
Joint Medical stores
Commercial Suppliers
National Medical Stores
From Another laboratory
Number of laboratories
(n=29)
14
15
14
7
 68.9% - delays in obtaining reagents from the medical stores.
 51.7% - Stock outs at the supply stores
 34.5% -consumables are ordered but no deliveries received
 6.9% -lack of information on how to make orders
 3.4% - inconsistent demands for laboratory tests, lack of response on placed
orders, delivery of what was not ordered and delivery of expired reagents
Alliance for the Prudent Use of Antibiotics
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Zambia: Sources and supply of bacteriological
laboratory consumables
Source
Medical Stores limited
National Medical Store
Commercial Suppliers
Number of laboratories
7
7
3
76.4% (13/17) of the laboratories admitted to experiencing problems in obtaining
reagents from suppliers.
23% (4/17) of the laboratories experienced problems with reagent stock out at the
medical stores.
58.8% (10/17), 41.2% (7/17) and, 11.8% (2/17) of the laboratories experienced
delays in receiving ordered reagents from medical stores, inconsistency in the supply
of laboratory consumables, and lack of knowledge on making orders, respectively.
15
Scores of Zambian Laboratories
Score Range 0-49%
Lundazi District Hospital
Mutendere Mission Hospital
Livingstone General Hospital
Score Range 50%-74%
Maina Soko Military Hospital
Mansa General Hospital
Chikankata Mission Hospital
Mpika General Hospital
Kasama General Hospital
Kitwe Central Hospital
Ndola Central Hospital
Monze Mission Hospital
Nchanga South Hospital
Lusaka Trust Hospital
Alliance for the Prudent Use of Antibiotics
Score Range >75%
University of Zambia
Teaching Hospital *
Tropical Disease Research
Center * (research facility)
Arthur Davidson (Pediatric)
Hospital Laboratory*
Chest Disease Laboratory
* (national laboratory)
16
Scores of Ugandan Laboratories
Score Range 0-49%
Score Range 50%-74%
Kibuli Hospital
Kisubi Hospital
Lira Regional Referral
Hospital
Cure Hospital
Jinja Regional Referral
Hospital
Soroti Hospital
Kuluva Hospital
Masaka Regional Referral
Hospital
Arua Regional Referral
hospital
Lacor Hospital
Kiwoko Hospital
Kagando hospital
Nsambya Hospital
Kitovu Hospital
Tororo Hospital
Entebbe Hospital
Kibuli Hospital
Gulu Independent
Hospital
Rubaga Hospital
Score Range >75%
Mbarara Regional Referral
Hospital *
Kitovu Hospital *
Mulago National Referral
Hospital *
Mengo Hospital *
Mbale Hospital*
International Hospital Kampala
*
Butabika Regional Referral
Hospital
17
Zambia: Quality assurance in isolation, characterization of
microorganisms and antibiotic susceptibility testing
 4/17 laboratories (23.5%) had external quality control
procedures for antibiotic susceptibility testing,
performed by:



Acid-fast bacilli (AFB) microscopy
National TB reference Laboratory
National Institute for Communicable Diseases (NICD)/WHO,
South Africa
18
Zambia: Availability and use of the WHONET
software
 Only the University Teaching Hospital, Lusaka laboratory is
currently using WHONET software (version 5.1 installed in
May 2009)
 There is no national policy on antibiotic resistance
surveillance
19
Uganda: Quality assurance in isolation, characterization of
microorganisms and antibiotic susceptibility testing
 Only 6.6% have external quality control procedures
for Antibiotic Susceptibility, performed by:
 Center for Public Health Laboratories (CPHL)
Availability and use of the WHONET software
 None (0/29) of the surveyed laboratories installed or used
the WHONET software to monitor AMR.
Alliance for the Prudent Use of Antibiotics
20
Availability of Laboratory Equipment
Bactec at the Lusaka University Teaching Hospital Microbiology Laboratory, 2009
The survey of laboratory
equipment examined the
following:
I. Availability of the essential
equipment required to
provide routine clinical
diagnostics
II. Functioning of equipment
III. Equipment operation and
maintenance standards
IV. Equipment storage
conditions, and the records
of equipment calibration
21
Availability of Laboratory Equipment
Most of the surveyed
laboratories had the essential
equipment needed to
perform clinical diagnostics
Some of this equipment
was not in working
condition.
Most of the laboratory
equipment was not regularly
calibrated and maintained.
22
Mulago National Referral Hospital
&
Makerere School of Medicine, Kampala
Alliance for the Prudent Use of Antibiotics
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Charges of tests (US$) performed by Zambian laboratories
$5.81
30000
25000
20000
15000
10000
$4.18
$3.51 $3.84
$2.74
$2.19
$1.62 $1.78
5000
CSF
Stool
Hemoglobin
FBC
Blood
Sputum
Urinalysis
0
Malaria
Cost in Zambian Kwacha
11/17 laboratories charged user fees for clinical tests
Laboratory test
Average costs for performing blood smear for malaria, urinalysis,
sputum, blood , CSF , and stool cultures by different laboratories
24
Charges of tests (US$) performed by Ugandan laboratories
55.2 % (16/29) of the laboratories surveyed charged fees for each laboratory test.
The highest cost was of CSF and blood cultures
Average costs for performing blood smear for malaria, urinalysis, Sputum,
blood culture, CSF cultures, and stool cultures by different laboratories
Alliance for the Prudent Use of Antibiotics
25
Specimen handling
Some laboratories discarded
specimens a few days after
testing.
Most of the laboratories had
no criteria for sample disposal.
Alliance for the Prudent Use of Antibiotics
26
Conclusions and Major Constraints
1. Limited antibiotics susceptibility testing capabilities.
2. Essential equipment is available in most laboratories, but
often, the equipment is not maintained, calibrated, or in
working condition
3. No standard specimen handling procedures
4. No sample disposal procedures
5. No antibiotic resistance surveillance systems in place in
most hospitals
27
Conclusion and major constrains (continued)
6. Lack of adequate funding for laboratory equipment,
7.
8.
9.
10.
reagents, staff, stationery, and consumables
No standard procedures on antibiotic susceptibility testing
Problems with reagent stock-outs from suppliers and
medical stores
Delays in receiving laboratory supplies
Inconsistent reporting of notable diseases to national and
district health authorities
28
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