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

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

admissions
deaths

<1
740
224

1-2
148
23

3-5
147
22

Older
87
6

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

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

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

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

29 Surveyed Laboratories in Uganda

Alliance for the Prudent Use of Antibiotics

10

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

14

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

23

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

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

29