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
Antibiotic Resistance: Situation Analysis and Needs Assessment in Uganda and Zambia (AR-SANA)
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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
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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
AMR in Uganda: Key Findings
Antibiotic resistance profiles of S. pneumoniae from 2005- 2007 in Kampala
0
20
40
60
80
100
120
Ampi
cillin
Co-tr
imox
azol
e
Peni
cillin
Cip
roflo
xacin
Cef
tazid
ime
Cef
triax
one
Eryt
hrom
ycin
Chl
oram
phen
icol
Gen
tam
ycin
Res
istan
ce F
requ
ency
Antibiotic
2005 2006 2007 2008
Alliance for the Prudent Use of Antibiotics
Data from Mulago Hospital Laboratory Data
Purpose of the laboratory surveyTo 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 testingIV.Availability of a system for quality control in the laboratoriesV.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 decisionsVII.Economic situation of the survey laboratories VIII.Availability of the WHONET software for antimicrobial
resistance surveillance
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Method of laboratory survey17 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 outThe 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
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17 Laboratories Surveyed in Zambia
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Monze, Livingstone, Chikankata, Mutendere
Maina Soko, Lusaka Trust, Chest
Disease, UTH
Kasama, MpikaMansa
Lundazi
Ndola, Kitwe, Tropical Dis. , Nchanga, Arthur Davidson
29 Surveyed Laboratories in Uganda
Alliance for the Prudent Use of Antibiotics 10
Laboratory survey Components
I. Laboratory staffing and trainingsII. Laboratory equipmentIII. Laboratory supply logisticsIV. Laboratory record keeping for supplies
managementV. Sources of laboratory reagentsVI. Specimen collection, handling and labellingVII.Laboratory specific capacityVIII.Structure of reporting laboratory resultsIX. Quality control proceduresX. Cost of laboratory testing and sources of funding
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Microbiology Laboratory
University Teaching Hospital of Lusaka
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Microbiology Laboratory
University Teaching Hospital of Lusaka
Uganda: Sources and supply of bacteriological laboratory consumables
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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
Source of reagents Number of laboratories (n=29)
Joint Medical stores 14 Commercial Suppliers 15 National Medical Stores 14 From Another laboratory 7
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.
Zambia: Sources and supply of bacteriological laboratory consumables
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Source Number of laboratories Medical Stores limited 7 National Medical Store 7 Commercial Suppliers 3
Alliance for the Prudent Use of Antibiotics 16
Score Range 0-49% Score Range 50%-74% Score Range >75% Lundazi District HospitalMutendere Mission Hospital Livingstone General Hospital
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 HospitalLusaka Trust Hospital
University of Zambia Teaching Hospital *Tropical Disease Research Center * (research facility)Arthur Davidson (Pediatric) Hospital Laboratory* Chest Disease Laboratory * (national laboratory)
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Score Range 0-49% Score Range 50%-74% Score Range >75% 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
Mbarara Regional Referral Hospital *Kitovu Hospital *Mulago National Referral Hospital *Mengo Hospital *Mbale Hospital* International Hospital Kampala *Butabika Regional Referral Hospital
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
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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
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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)
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None (0/29) of the surveyed laboratories installed or used the WHONET software to monitor AMR.
Availability and use of the WHONET software
Availability of Laboratory Equipment
The survey of laboratory equipment examined the following:I.Availability of the essential equipment required to provide routine clinical diagnosticsII.Functioning of equipmentIII.Equipment operation and maintenance standardsIV.Equipment storage conditions, and the records of equipment calibration Bactec at the Lusaka University Teaching Hospital
Microbiology Laboratory, 2009
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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.
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Mulago National Referral Hospital
& Makerere School of Medicine,
Kampala
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Charges of tests (US$) performed by Zambian laboratories
11/17 laboratories charged user fees for clinical tests
Average costs for performing blood smear for malaria, urinalysis, sputum, blood , CSF , and stool cultures by different laboratories 24
Charges of tests (US$) 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
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Specimen handling
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Some laboratories discarded specimens a few days after testing.
Most of the laboratories had no criteria for sample disposal.
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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 procedures4. No sample disposal procedures5. No antibiotic resistance surveillance systems
in place in most hospitals27
6. Lack of adequate funding for laboratory equipment, reagents, staff, stationery, and consumables
7. No standard procedures on antibiotic susceptibility testing
8. Problems with reagent stock-outs from suppliers and medical stores
9. Delays in receiving laboratory supplies10.Inconsistent reporting of notable diseases to
national and district health authorities
Conclusion and major constrains (continued)
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