Opportunities and Challenges for Improving Anti-Microbial Stewardship in Low- and Middle-Income Countries; Lessons Learnt from the Maternal Sepsis Intervention in Western Uganda

Abstract

This paper presents findings from an action-research intervention designed to identify ways of improving antimicrobial stewardship in a Ugandan Regional Referral Hospital. Building on an existing health partnership and extensive action-research on maternal health, it focused on maternal sepsis. Sepsis is one of the main causes of maternal mortality in Uganda and surgical site infection, a major contributing factor. Post-natal wards also consume the largest volume of antibiotics. The findings from the Maternal Sepsis Intervention demonstrate the potential for remarkable changes in health worker behaviour through multi-disciplinary engagement. Nurses and midwives create the connective tissue linking pharmacy, laboratory scientists and junior doctors to support an evidence-based response to prescribing. These multi-disciplinary ‘huddles’ form a necessary, but insufficient, grounding for active clinical pharmacy. The impact on antimicrobial stewardship and maternal mortality and morbidity is ultimately limited by very poor and inconsistent access to antibiotics and supplies. Insufficient and predictable stock-outs undermine behaviour change frustrating health workers’ ability to exercise their knowledge and skill for the benefit of their patients. This escalates healthcare costs and contributes to anti-microbial resistance.

Access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda: a qualitative study

“…The NAP emphasizes the need to strengthen the evidence base on antimicrobial use to inform policy including through research [ 9 ]. However, most of the research on AMS in the country to date has been from large health facilities [ 27 – 29 ], with minimal literature from community settings. Given that AMR is a complex public health problem that concerns many sectors, there is need for more evidence on access and use of antimicrobials among humans and animals particularly in the community, as well as disposal of antimicrobials at household level.…”

Impact of accreditation on health care services performance in Kiryandongo district, Uganda: a longitudinal study

“…Kiryandongo district is one of the 146 districts in Uganda [16]. The district has thirty-nine (39) health facilities constituting of twenty-one (21) Government, fourteen (14) Private for Profit and four (4)-Private not for profit (PNFP). These facilities serve the population of Kiryandongo and the surrounding districts of Masindi, Nakasongola, Oyam, Apac, Amuru and Nwoya.…”

“…Despite the tremendous achievements accrued by the implementation of laboratory quality management system initiatives in Uganda, laboratory services still face challenges including stock out of health commodities, inadequate human resource, limited testing scopes and inadequate funding [13,14]. These challenges compromise health care performance, and attainment of national and international goals.…”

Antibiotic resistance profiles and population structure of disease-associated Staphylococcus aureus infecting patients in Fort Portal Regional Referral Hospital, Western Uganda

“…A study of post-operative sepsis cases in rural Eastern Uganda [35] reported 14 % S. aureus isolates to be resistant to five different classes of antibiotics and 3 % resistant to six different classes [35]. Whilst the Ugandan national action plan (UNAP) reports prevalence of MRSA in healthcare settings at 2-50 % [23], the WHO AMR global report on surveillance (2014) found overall MRSA prevalence to range from 12-80 % across Africa and to exceed 20 % in all six WHO regions [36]. There have been reports of more than 80 % MRSA prevalence in African, American and Western Pacific regions [36].…”

“…This study is part of a multi-disciplinary intervention at FPRRH linking laboratory testing with training of health professionals in understanding common drivers of AMR aiming to reduce unnecessary and ineffective use of antibiotics in line with the UNAP [ 23 ]. We combine existing hospital AST data with whole genome sequencing to investigate antibiotic resistance profiles, population structure and virulence gene carriage of S. aureus isolated from a range of infection sites including wounds, blood, and the urinary tract, in a region with little previous published data, towards better informed treatment practice and infection/AMR control policies.…”