Strengthening Antimicrobial Resistance Diagnostic Capacity in Rural Rwanda: A Feasibility Assessment

Abstract

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use. Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda. Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system. Results: There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590. Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings.

A Situation Analysis of the Capacity of Laboratories in Zambia to Conduct Surveillance of Antimicrobial Resistance: Strengths, Weaknesses, Opportunities, and Challenges

“…This was due to poor access to LIS, low participation in external quality assessment programs for cultures, severe infrastructural gaps and lack of equipment [61]. In Rwanda, critical gaps in equipment and supplies were found in district hospitals, similar to those found in our study [67]. Our findings and those reported in other African countries conform with earlier findings that there is a lack of proper reliable, cost-effective and easy-to-use AMR diagnostic tools, particularly in routine diagnostic laboratories [65,68].…”

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda

“…Due to lack of infrastructure for pathology confirmations, this is the main means of SSI diagnosis in this rural hospital, similar to many other rural SSA settings. 48 49 Since we are interested in identifying strategies that imitate a facility visit without the burden of travel, the GP diagnosis is a suitable gold standard in this context. Finally, for logistical reasons, the telemedicine screening and physical examination were 1 day apart.…”

“…A third limitation is that the gold standard for SSI diagnosis is a GP physical examination, without isolating pathological organisms through swab or fluid culture. Due to lack of infrastructure for pathology confirmations, this is the main means of SSI diagnosis in this rural hospital, similar to many other rural SSA settings 48 49. Since we are interested in identifying strategies that imitate a facility visit without the burden of travel, the GP diagnosis is a suitable gold standard in this context.…”

Image-based surgical site infection algorithms to support home-based post-cesarean monitoring: Lessons from Rwanda

“…In addition to clinical examination, confirmative pathology could be used. However, many rural health facilities in LMICs do not have access to bacteriology labs and we found establishing such capacity incredibly challenging [12]. Further, even when available, non-pathogenic bacteria can be misdetected on wound swabs, adding uncertainty to diagnoses [13].…”