Fighting the Invisible Enemy: Ugandan medics take on antimicrobial resistance

In the second part of this series, we show how frontline medics are fighting for a future where routine infections do not become deadly again

Kampala, Uganda | IAN KATUSIIME | Dr Lorna Atikoro works at Kiruddu National Referral Hospital and describes herself as a soldier in the fight against antimicrobial resistance (AMR). She recalls a recent case where drug resistance altered a patient’s outcome and forced her to rethink the treatment strategy. The patient was a 43-year-old man who came into hospital with ulcers on his legs that made him unable to walk.

“He had a long-standing history of diabetes that had been poorly controlled, consequently making his kidneys fail. As part of his management plan, a urinary catheter was inserted to both monitor his urine output and make it easy for him to pass urine as he was being taken care of by his elderly mother who couldn’t take him to the washroom multiple times,” Dr Atikoro told The Independent in an interview.

As he was immobilized for a long time, he got bed sores that were extensive and these got infected. A pus swab was taken to the microbiology laboratory and his results showed a multidrug resistant bacterium. “Later, the urine in his urine bag turned purple in color, a condition known as ‘purple bag syndrome’ which is as a result of a very high bacterial load in one’s urine,” she narrated.

A urine culture showed a multidrug resistant Klebsiella pneumoniae that was resistant to all the antibiotics available in the hospital. “Unfortunately, because of this, he eventually got a blood stream infection as the infection spread consequently leading to his death,” she said.

Dr Atikoro is a microbiologist who has participated in the designing of institutional guidelines at Kiruddu Hospital. The hospital handles some of the most complicated infections in the country. She shared how she juggles clinical decision-making, patient expectations, and the emotional weight of limited treatment options.

“The last line of antibiotics for multidrug resistant infections is known as ‘Reserve antibiotics’ according to the WHO AWaRe classification of antibiotics. Unfortunately, most of these drugs are expensive and sometimes not available even in private pharmacies,” she explained.

Typically, if a patient has a multidrug resistant infection, she says the doctors will hold a family conference where the limited treatment options are discussed with both the patients and their care givers. She adds that doctors also resort to the Reserve antibiotics if available in the hospital or advise the patient’s care givers to purchase them from a private pharmacy.

“However, if the patient’s prognosis is poor, we involve the palliative care team to prepare the patient and their caretakers for the likely bad outcome,” she said.

Message for government

Frontline soldiers like Dr Atikoro need diagnostics, stewardship protocols, and access to effective drugs for the battle against AMR. She has a message for policymakers who may underestimate the threat Uganda’ s national health system faces.

“The extent of the burden of AMR can best be estimated by ensuring the presence of
microbiology laboratories, trained personnel and consumables in both district and referral hospitals. The results from these laboratories would then enable each healthcare facility to develop a local antibiogram that would guide empirical therapies and guide the different hospitals on the antibiotics to procure.”

She says Kiruddu Hospital currently has a functional microbiology laboratory that is accredited by the South African National Accreditation System (SANAS) and this has enabled us to know the extent and trends of AMR in the hospital.

However, the hospital routinely suffers stock outs of consumables. She adds that in spite of Kiruddu being a referral hospital, some patients are referred late, when the infections have already led to multi organ failure and antibiotics grossly abused thus the need for microbiology services at all regional referrals and district hospitals.

“I would also advocate for the government to employ clinical microbiologists in all regional and national referral hospitals; these would play a pivotal role in surveillance of outbreaks of multidrug resistant infections and also lead the antimicrobial stewardship rounds consequently preventing the spread of AMR.”

Some doctors are adapting their medical models to deal with the healthcare challenge of anti-microbial resistance. For Dr Prosper Ahimbisibwe, co-founder of a medical start up called MSCAN, he drafts the clinical protocols for MSCAN deployments for their remote sites.

“Infection Prevention and Control (IPC), a core part of the Standard Operating Protocols (SOPs), is emphasized by disinfecting MSCAN probes daily using ultrasound gel and then wiping them with tissue. Additionally, each pregnant mother is provided with her own Macintosh cloth to lie on.”

Dr Ahimbisibwe like other medics is concerned by the “normalized culture” of self-medication where Ugandans treat a common cold or flu with an antibiotic without consulting a medical doctor.

“First and foremost, regulation must be enforced to require a prescription for the sale of any antibiotics from a pharmacy. The Ministry of Health Uganda can drive this, directing the Pharmacy Board, the Pharmaceutical Society of Uganda, and the Uganda Medical and Dental Practitioners Council.”

He calls for hospitals offering inpatient services, whether government-funded or private, to establish protocols for prescribing medications. “These protocols should include a robust system for performing culture and sensitivity tests, both routinely and for specific cases.”

Dr Andrew Kambugu, Executive Director of the Infectious Diseases Institute says the health procurement needs to change at a national level if there’s a chance of fighting AMR.

“We spend quite a bit of our budget buying antibiotics that are in a sense useless because these are the bugs that are not responding.”

He mentions the need to strengthen restrictive access to antibiotics so that they are prescribed and accessed appropriately. “Some of these are legislative actions including adjustments to the National Drug Authority Act.”

IDI formed a parliamentary forum on antimicrobial resistance headed by Charles Ayume, MP for Koboko Municipality in West Nile. Incidentally, TB, a major driver of AMR, is prevalent in the region. IDI is engaging parliamentarians to have more resources allocated towards tightening regulatory frameworks for antimicrobial resistance.

This was courtesy of a grant called CAMO-NET [Centers for Antimicrobial Optimisation Network] funded through The Wellcome Trust, a global charity foundation supporting health causes.

“We are doing advocacy to rally people around this cause. There’s a week in November globally recognised as an AMR awareness week where we really do a lot of community sensitization, talk about the national action plan and what needs to be done,” Dr Kambugu says.

He reckons that the most durable way to bring change in the AMR space is to have more educated communities so that we can stop the demand for unnecessary use of antimicrobials. Where people dictate to doctors

Dr Kambugu also underscores the need to break down traditional professional silos to effectively tackle the resistance burden. “The doctors think they are better than the veterinarians, the vets do not want to talk to the environment people but these bugs do not know those borders. AMR requires us to work collaboratively…the One Health approach.”

The cross disciplinary collaboration and dialogue has seen IDI team up with the faculty of veterinary sciences at Makerere University and the Ministry of Agriculture for effective responses.

One Health Platform

The Government of Uganda has a One Health platform that brings together the Ministry of Health, Ministry of Agriculture, Ministry of Water and Environment, and Uganda Wildlife Authority to deal with Anti-Microbial Resistance.

Under this, is the National Antimicrobial Resistance Subcommittee chaired by Dr Henry Kajambula. The committee is tasked with several activities including coordination and stewardship of the One Health approach since anti-microbial resistance is not limited to human health but to environment and animal health. In an interview with The Independent, he said one of the major challenges they faced was limited microbiology laboratory capacity.

“We had just about five labs that were from health facilities and stand alone private labs that were regularly doing microbiology testing. That has significantly improved. Now nearly all regional referrals have active microbiology labs. That was actually one of the key priorities during the first national action plan.”

Microbiology is how doctors find out the causes of infectious diseases and how to treat them using specimens like blood by examining them in the laboratory. Dr Kajambula adds that the lab testing is key in deciding when to give a patient antimicrobial treatment or to know which one to use. “It’s a gateway in determining how people use antimicrobials. It helps us collect data, do surveillance because we want to know the status of various organism infections so that we know which data we can use.”

He says that the data is also needed for making treatment guidelines and adds that private facilities are setting up microbiology labs. While surveillance and data collection has improved, there is still more work to do. “We are also trying to improve diagnostic stewardship. This means making people able to use that lab capacity optimally. We may have the labs but when they are not being used adequately.”

He explains that the goal here is to work with clinicians to make sure they utilize labs. “You have to train healthcare workers because there is a tendency of inappropriately prescribing antimicrobials.”

Training and education

Dr Kajambula says public awareness, training and education are major objectives of the AMR strategic plan. “One of the major drivers of antimicrobial resistance is their use. “Whether you use them right or wrong, you are driving resistance.” He adds, “People feign symptoms and use them. You are wasting the antimicrobials because they are a resource.”

He says the purpose of these training sessions are to enable healthcare providers to discern situations where they do not have to prescribe antibiotics when they are not needed. Talk shows, scientific conferences, and other forms of public communications are some of the undertakings to raise awareness on AMR.

The Sub-committee has collaborated with the National Council of Higher Education (NCHE) to address use of antimicrobials for healthcare workers when they are still at university. Similar engagements were held with the National Curriculum Development Centre (NCDC) to develop health education components for school children.

The other strategic issue of the committee is about infection prevention and control so that fewer people can use antimicrobials. This is being incorporated in health education programmes through basics such as hand hygiene and improved sanitation.

Dr Kajambula says going forward regulation needs to be strengthened to stem easy access to antibiotics over the counter in addition to effective monitoring of pharmacies. He adds that healthcare facilities are another factor due to the number of sick people that throng them.

“These people come with resistant organisms to the healthcare facilities where infection prevention and control measures are not adequate. That promotes spread of these organisms from one person to another within the facilities who then spread them to the communities.”

A major partner of Uganda’s efforts against anti-microbial resistance is the UK Fleming Fund which has built surveillance and lab capacity. USAID was a major player until it was shut down. The government of Uganda has been coming through with National Medical Stores (NMS) which has started stocking microbiology supplies.

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This story was supported by African Centre for Media Excellence