Abstract Introduction Methods Results Discussion Acknowledgements References About the Author(s) Lucas Ampaire Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda Abraham Muhindo Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda Patrick Orikiriza Epicentre Mbarara Research Centre, Mbarara, Uganda Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda Juliet Mwanga-Amumpaire Epicentre Mbarara Research Centre, Mbarara, Uganda Lisa Bebell Massachusetts General Hospital, Boston, Massachusetts, United States Yap Boum Epicentre Mbarara Research Centre, Mbarara, Uganda Citation Ampaire L, Muhindo A, Orikiriza P, et al. A review of antimicrobial resistance in East Africa. Afr J Lab Med. 2016;5(1), a432. http://dx.doi.org/10.4102/ajlm.v5i1.432

Review Article A review of antimicrobial resistance in East Africa Lucas Ampaire, Abraham Muhindo, Patrick Orikiriza, Juliet Mwanga-Amumpaire, Lisa Bebell, Yap Boum Received: 06 Mar. 2016; Accepted: 24 June 2016; Published: 15 Sept. 2016 Copyright: © 2016. The Author(s). Licensee: AOSIS. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background and objectives: Knowledge of local and regional antimicrobial resistance (AMR) is important for clinical decision making. However, surveillance capacity for AMR is lacking throughout East Africa, and current AMR data are sparse. We sought to address this gap by summarising all available high-quality data on AMR in the East Africa region. Method: We searched the PubMed database and African Journals Online archives in April and May 2015 using the search term ‘antimicrobial resistance AND sub-Saharan Africa’ to find articles published from 2005 onwards. Only full-text articles in English were included. Results: We included 12 published articles in our analysis. Most articles were on bloodstream infections, hospital-based and cross-sectional in design; a majority described either community- or hospital-acquired infections. High levels of AMR to commonly-used antibiotics were reported, including 50% – 100% resistance to ampicillin and cotrimoxazole infections, emerging resistance to gentamicin (20% – 47%) and relatively high levels of resistance to ceftriaxone (46% – 69%) among Gram-negative infections. Much of the resistance was reported to be in Klebsiella species and Escherichia coli. Among Gram-positive infections, extensive resistance was reported to ampicillin (100%), gentamicin and ceftriaxone (50% – 100%), with methicillin-resistant Staphylococcus aureus prevalence ranging from 2.6% – 4.0%. Conclusion: Overall, bacterial resistance was reported among commonly-used antibiotics (ampicillin, gentamicin and ceftriaxone), raising concern that these antibiotics may no longer be useful for treating moderate or severe bacterial infections in East Africa. Thus, empirical treatment of bacterial infections needs to be reconsidered and guided by local assessment of AMR. Improvements in the limited amount of quality data and lack of harmonisation in assessing the burden of AMR are also needed. Introduction Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill. (Dr Keiji Fukuda, WHO Assistant Director-General for Health Security) The benefits of appropriate antibiotic use to treat bacterial infections are well established, although all antibiotic use carries a risk of inducing antimicrobial resistance (AMR). Throughout East Africa there is a heavy burden of community-acquired infectious disease.1 Unfortunately, the surveillance capacity for AMR is minimal in most East African countries, and current data on AMR patterns of common pathogenic bacteria are sparse.2 In addition, World Health Organization (WHO) surveillance reports indicate that there is inadequate coordination and harmonisation, compromising the ability to assess and monitor the situation.3 As a result, in these resource-constrained settings, the choice of antibiotic is often not based on known bacterial susceptibilities. Limited capacity for microbiology testing in East Africa coupled with a high burden of life-threatening bacterial infections reinforces a pattern of antibiotic prescription that is largely empirical, where AMR is detected only by therapeutic failure. Compounding the problem is the small repertoire of antimicrobials available in these settings, which are often of poor quality, when not counterfeit. In addition, in low-resource settings, antibiotics are often sold over the counter with minimal product regulation, oversight or quality control.4 The above, coupled with poor hygiene and infection control practices, may also spread community and/or hospital-acquired drug-resistant pathogens, further exacerbating the problem.5 The WHO global report3 on AMR indicates that resistance of common bacteria has reached alarming levels in many parts of the world. Furthermore, the report shows high proportions of resistance to third-generation cephalosporins and carbapenems: up to 54% among Escherichia coli and Klebsiella pneumoniae. Unfortunately, in East Africa, few good studies exist documenting the extent of AMR. The Global Antibiotic Resistance Partnership conducted by the Uganda National Academy of Sciences recently revealed worsening trends of resistance and diminishing effectiveness of antibiotics in Uganda.6 Some affordable drugs, such as penicillin G and cotrimoxazole, have been reported to have resistance at or near 100%.6 Although such reports are concerning, the burden of AMR in the East Africa region is not well published. Additionally, knowledge of the situation in many parts of the world further complicates the problem.3 Better knowledge of the burden and proportion of infections caused by drug-resistant bacteria in low-resource settings would raise awareness of the need to prevent the rise and spread of drug resistance. Understanding current levels of AMR throughout East Africa could improve clinical practice by guiding empirical antibiotic choice. Toward this end, we reviewed the available evidence on the burden of AMR among bacterial pathogens in East Africa in order to inform current clinical practice and future research interventions to address antibiotic resistance. Methods Literature review We searched the PubMed database and African Journals Online archives in April and May 2015. We used the term ‘antimicrobial resistance AND sub-Saharan Africa’ to find articles published from 2005 onwards. Only articles in English were included. Study selection criteria Full-text articles were included if they reported the proportion of antibiotic resistance among clinical isolates of pathogenic bacteria collected from inpatients and outpatients in any of the following East African countries: Uganda, Kenya, Tanzania, Rwanda, Ethiopia and Democratic Republic of Congo. Eligible studies were required to describe the patient population studied, organisms isolated, specific laboratory methods used for the determination of pathogen antimicrobial sensitivity patterns, and an interpretation of the specific minimum inhibitory concentration breakpoints or the diameter of the zone of inhibition of the antibiotics tested as described by the Clinical and Laboratory Standards Institute.7,8 Both adult and paediatric patient populations were included, but case reports were excluded from the review as has been done previously.9 For overlapping studies reporting on the same clinical isolates, only the study with the largest sample size was included. In an effort to incorporate contemporary, relevant AMR data, only studies published from 2005 onwards were included in the review. Data extraction The extracted data included bacterial species isolated, the number of isolates tested for AMR, specific antibiotics tested for resistance, and percentage of organisms resistant to each antibiotic. Extracted data were grouped on the basis of whether they caused bloodstream infections or other infections. Results We initially identified 150 articles: 140 from PubMed and 10 from African Journals Online. Full-text articles were available for 34 papers identified by the search. Of the remaining 116 manuscripts, only abstracts were freely available for 105 articles; 11 presented information on anti-tuberculosis drug resistance and lacked information on non-mycobacterial infections, which rendered them ineligible for inclusion in this review. Of the 34 full-text articles available, 22 were excluded, because the data presented were from non-East African countries that were inseparable from data presented about East African countries (n = 5) or their laboratory methods were not well defined (n = 17) (Figure 1). The remaining 12 articles were included in this review, six describing AMR patterns in Uganda,10,11,12,13,14,15 five in Ethiopia16,17,18,19,20 and one in Tanzania21 (Table 1). Neither studies from Rwanda nor studies from the Democratic Republic of the Congo met inclusion criteria for this review. All studies were hospital-based and cross-sectional in design, and the majority described both community- and hospital-acquired infections. Four studies presented data on bloodstream infection, seven focused on other infections excluding bloodstream infections and one reported clinical specimens from multiple anatomical sites. FIGURE 1: Selection of publications for inclusion in this review. TABLE 1: Summary of East Africa-based studies included in the analysis. Antimicrobial resistance patterns Bloodstream infections According to the disk diffusion methods used in studies included in this review, pathogens exhibited relatively high levels of resistance to antibiotics commonly used in East Africa. For Gram-negative organisms (Table 2), 50% – 100% resistance was reported to ampicillin and cotrimoxazole, two of the most frequently-prescribed antibiotics in this region.16 High levels of resistance to ampicillin among children with bloodstream infections (75% – 100%)7,10,16 were also reported, as were lower, but significant, levels of resistance to gentamicin (20% – 47%).7,10,16 Among Gram-positive organisms isolated from bloodstream infections, overall relatively low levels of resistance were reported to gentamycin, ampicillin and chloramphenicol (4% – 12%).10,11 However, studies reporting specifically on hospital-acquired strains noted high-level resistance to ampicillin, gentamycin, chloramphenicol and trimethoprim-sulfamethoxazole (29%).11,19 TABLE 2: Antibiotic resistance patterns among patients with bloodstream infections. Non-bloodstream infections Surgical site infections Among organisms isolated from surgical site infections in hospitalised patients, Staphylococcus aureus and coagulase-negative Staphylococcus were the most common Gram-positive organisms, whereas Klebsiella spp., Proteus spp. and E. coli were the most common Gram-negative organisms10,16,22 (Table 3). Multiple studies reported 100% resistance to ampicillin for surgical site infections among hospitalised adults.16,22 There was also notable resistance of Gram-positive organisms to gentamicin and ceftriaxone in post-operative nosocomial isolates (50% – 100%), with methicillin-resistant Staphylococcus aureus (MRSA) prevalence ranging from 2.6% – 4.0%.16 TABLE 3: Antibiotic resistance patterns among patients with other, non-bloodstream infections. Urinary tract infections High-level resistance to ampicillin (50% – 100%) was seen in urinary tract infections, where E. coli was the most common pathogen.16,18 Citrobacter freundii was a major cause of urinary tract infections in one study focused on obstetric fistula patients, with resistance to ampicillin, gentamicin, and ceftriaxone ranging from 46% – 69%.18 Other causative organisms of urinary tract infections, such as Klebsiella spp., Enterobacter spp. and Proteus spp., also showed significant resistance to ampicillin, gentamycin and ceftriaxone, some of the most commonly-used antibiotics in East Africa.16,18 There was also high-level resistance reported of Neisseria gonorrhoeae to ciprofloxacin (81%) among sex workers in Uganda.21 Gastrointestinal tract infections Salmonella spp. in stool isolates from children under five years of age demonstrated complete resistance to ceftriaxone (100%). From the gastrointestinal tract, the commonly isolated bacteria were Campylobacter spp. and Shigella spp. Campylobacter spp. showed moderate amounts of resistance to ampicillin (30%) and high-level resistance to gentamicin (70%). Among Shigella spp., relatively high numbers were resistant to ampicillin (63%), although resistance to gentamycin was lower at 27% in one Ethiopian study.20 Multiple body sites One study from Uganda on phenotypic clindamycin resistance found that 109 (36%) of S. aureus isolates were resistant to clindamycin, of which 9 (3%) were constitutively resistant and 100 (33.3%) were inducibly resistant. In this study, S. aureus also showed significant resistance to trimethoprim-sulfamethoxazole (62%) and oxacilin (36%), with a demonstrated prevalence of MRSA equal to 36%.12 Resistance to vancomycin, one of the last-line drugs for treating MRSA, was also found (7.3%).12 Discussion In this review, we summarise the findings of 12 studies that demonstrate significant resistance across the East Africa region to antibiotics important for everyday use. Overall, although AMR varies throughout the region, we found that most Gram-negative organisms have limited susceptibility to ampicillin, ceftriaxone and gentamicin, which are commonly-used first-line empirical antibiotics in this region and recommended by the WHO Integrated Management of Childhood Illness for treatment of severely-ill infants. There was also significant resistance to cotrimoxazole, penicillins, quinolones, cephalosporins and aminoglycosides among Gram-positive organisms. Several published papers we reviewed reported single bacterial isolates resistant to multiple antibiotics. Antibiotic resistance to multiple drugs was most common among Gram-negative organisms isolated from hospital-acquired infections in post-operative patients and hospitalised adults.16,23 However, the susceptibility of Gram-negative organisms to ciprofloxacin was generally reported to be good; thus, this may be the drug of choice for empirical use against post-operative nosocomial infections with Gram-negative organisms. The finding of multi-drug resistance in this population suggests that efforts to promote appropriate antibiotic use and microbiological sampling of infected patients should be targeted to these groups in low-resource settings. The evidence presented here indicates that AMR, especially to the widely-used antibiotics (ampicillin, tetracyclines and trimethoprim-sulfamethoxazole), is prevalent and common in East Africa and may be a growing problem, especially among hospitalised and post-operative patients. However, resistance is likely under-reported in this region as noted by the WHO Global Report on AMR in 2014,3 due to limited availability of diagnostic testing, microbiology support and limited comparability of laboratory standards. Many of the same factors leading to the inability to test clinical isolates for antimicrobial susceptibility contribute to antibiotic overuse and misuse when laboratory data are lacking and can contribute to exacerbation of AMR. Even when information about AMR is available, it may not be properly communicated to those prescribing medications in East Africa, due to inadequate national laboratory strategic plans throughout the region. In addition, guidelines regarding appropriate selection of drugs are inadequate.11,18 Compounding these problems is a lack of rigorous infection control procedures, all of which could lead to the development and spread of antibiotic resistant bacteria. These factors combine to support the spread of existing AMR throughout East Africa. Preventing the development and spread of antimicrobial resistance AMR is likely to become an even greater problem in East Africa and may be exacerbated by overuse of antibiotics, the lack of oversight of antibiotic prescription, and the paucity of relevant local data on AMR. To address these issues, existing antimicrobial stewardship programmes should be strengthened or, where they are not yet in place, they should be developed and implemented in all regional referral hospitals in response to these challenges. Based on our findings, an area of particular focus should be hospitalised patients. Existing but limited resources should be directed equally at discovering the causes and at appropriate treatment of infections in this population. Additionally, there is a need to urgently scale-up training of both laboratory and pharmacy staff in antibiotic stewardship at health facilities where laboratory investigations are available. This is critical in communicating with clinicians, who are the cornerstone of proper management of patients with infections, especially with regard to the use of antibiotics. There is also need to regularly conduct antibiotic resistance surveys to establish evidence-based and locally-relevant antibiotic resistance information that would be helpful in creating guidelines to improve clinical practice. The implementation of the 2009 WHO global strategy for containment of AMR through inter-continental-wide surveillance programmes as a health systems approach12,23,24,25 has met with a number of challenges. In low- and middle-income countries, implementing the strategy has proven difficult, because human and financial resources and microbiology expertise are insufficient. In addition, it is difficult to obtain appropriate sample sizes for an accurate representation of resistance patterns. Novel approaches to antimicrobial surveillance are therefore needed for low-resource settings, which include the development of surveillance programmes utilising smaller sample sizes to provide locally-relevant AMR patterns and to encourage appropriate empirical antimicrobial therapy.26 Moreover, the development of new point-of-care diagnostic tools able to detect AMR in a cost-effective way will improve patient management and limit the emergence of drug resistance. Lastly, from among the total of 150 publications we identified, we considered only 12 due to the lack of standardisation and quality of the methodology and reporting. This highlights the scarcity of good quality data that could allow stakeholders to assess the real burden of AMR. Thus, better standardised research protocols are needed to evaluate the emergence of AMR in different settings to obtain comparable results and implement tailor-made interventions. Conclusion Based on the findings in this review, resistance to commonly-used antibiotics is prevalent in East Africa. Multi-drug resistance has been noted as a rising threat in the region and threatens to further complicate the drug resistance burden, especially for non-bloodstream infections where a single isolate may be resistant to more than one antibiotic drug of choice in different or similar drug lines. Data from interventional studies designed to reduce AMR are particularly lacking in the East African context, where infectious disease prevalence is high. The profound lack of data on hospital-acquired infections and prevalence of AMR in low-income East African countries calls for vigorous investigation and surveillance to better define the problem. There is a need for countries to promote acceptance of antimicrobial stewardship as a programmatic strategy, including pharmacy management, laboratory quality control, complete microbiology investigations and creation and dissemination of regional standard antibiograms. Acknowledgements We are grateful to Dan Nyehangane and Associate Professor Apecu O. Richard for their critical review of the manuscript and the Uganda Research Student Support Fund for their assistance. Competing interests The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. Authors’ contributions This work was carried out in collaboration between all authors. Y.B. was the project leader. L.A. and A.M. performed the literature search, data analysis, and wrote the first draft of the manuscript and managed manuscript revisions. L.B. participated in data analysis and manuscript writing and revisions. P.O., J.M.-A. and Y.B. participated in manuscript writing and revisions. All authors read and approved the final manuscript. References Murray CJL, Ezzati M, Flaxman AD, et al. GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology. Lancet. 2012;380(9859):2055–2058. http://dx.doi.org/10.1016/S0140-6736(12)62134-5 Okeke IN, Aboderin OA, Byarugaba DK, et al. Growing problem of multidrug-resistant enteric pathogens in Africa. Emerg Infect Dis. 2007;13(11):1640–1646. http://dx.doi.org/10.3201/eid1311.070674 World Health Organization. Antimicrobial resistance: global report on surveillance. WHO Press: Geneva, Switzerland; 2014. Cockburn R, Newton PN, Agyarko EK, et al. 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Infection and Drug Resistance  vol: Volume 14  first page: 277  year: 2021  
doi: 10.2147/IDR.S289687

19. Implementation of the World Health Organization Global Antimicrobial Resistance Surveillance System in Uganda, 2015-2020: Mixed-Methods Study Using National Surveillance Data
Susan Nabadda, Francis Kakooza, Reuben Kiggundu, Richard Walwema, Joel Bazira, Jonathan Mayito, Ibrahimm Mugerwa, Musa Sekamatte, Andrew Kambugu, Mohammed Lamorde, Henry Kajumbula, Henry Mwebasa
JMIR Public Health and Surveillance  vol: 7  issue: 10  first page: e29954  year: 2021  
doi: 10.2196/29954

20. Trends of Antibacterial Resistance at the National Reference Laboratory in Cameroon: Comparison of the Situation between 2010 and 2017
M. Massongo, L. Ngando, E. W. Pefura Yone, Ariane NZouankeu, W. Mbanzouen, M. C. Fonkoua, A. Ngandjio, J. Tchatchueng, D. Barger, M. C. Tejiokem, Khalid Mehmood
BioMed Research International  vol: 2021  issue: 1  year: 2021  
doi: 10.1155/2021/9957112

21. Antibiotic Prevalence Study and Factors Influencing Prescription of WHO Watch Category Antibiotic Ceftriaxone in a Tertiary Care Private Not for Profit Hospital in Uganda
Mark Kizito, Rejani Lalitha, Henry Kajumbula, Ronald Ssenyonga, David Muyanja, Pauline Byakika-Kibwika
Antibiotics  vol: 10  issue: 10  first page: 1167  year: 2021  
doi: 10.3390/antibiotics10101167

22. Phylogenetic Groups and Antimicrobial Susceptibility Patterns of Escherichia coli from Healthy Chicken in Eastern and Central Uganda
Winston Kabiswa, Ann Nanteza, Gabriel Tumwine, Samuel Majalija
Journal of Veterinary Medicine  vol: 2018  first page: 1  year: 2018  
doi: 10.1155/2018/9126467

23. The need to improve antimicrobial susceptibility testing capacity in Ugandan health facilities: insights from a surveillance primer
Duku Chaplain, Butti Ben Asutaku, Muhammad Mona, Douglas Bulafu, Dickson Aruhomukama
Antimicrobial Resistance & Infection Control  vol: 11  issue: 1  year: 2022  
doi: 10.1186/s13756-022-01072-4

24. Environmental resistome risks of wastewaters and aquatic environments deciphered by shotgun metagenomic assembly
Mutshiene Deogratias Ekwanzala, John Barr Dewar, Maggy Ndombo Benteke Momba
Ecotoxicology and Environmental Safety  vol: 197  first page: 110612  year: 2020  
doi: 10.1016/j.ecoenv.2020.110612

25. Efforts to Identify and Combat Antimicrobial Resistance in Uganda: A Systematic Review
Mark Kivumbi, Claire Standley
Tropical Medicine and Infectious Disease  vol: 6  issue: 2  first page: 86  year: 2021  
doi: 10.3390/tropicalmed6020086

26. Resistance pattern of infected chronic wound isolates and factors associated with bacterial resistance to third generation cephalosporins at Mbarara Regional Referral Hospital, Uganda
Wangoye Khalim, James Mwesigye, Martin Tungotyo, Silvano Samba Twinomujuni, Grzegorz Woźniakowski
PLOS ONE  vol: 16  issue: 12  first page: e0261264  year: 2021  
doi: 10.1371/journal.pone.0261264

27. Diagnostic Underuse and Antimicrobial Resistance Patterns Among Hospitalized Children in a National Referral Hospital in Kenya: A Five-Year Retrospective Study
Veronicah M. Chuchu, Teresa Ita, Irene Inwani, Julius Oyugi, S. M. Thumbi, Sylvia Omulo
Antibiotics  vol: 14  issue: 9  first page: 872  year: 2025  
doi: 10.3390/antibiotics14090872

28. Interactive effects of environment on antimicrobial activity of extracts of the termite Macrotermes subhyalinus (Blattodea: Termitidae)
Miriam Awuor Oluoch, Benson Odhiambo Onyango, Peter Bulli, Ellen Klinger
Journal of Insect Science  vol: 25  issue: 6  year: 2025  
doi: 10.1093/jisesa/ieaf075

29. Qualitative drivers of postoperative prophylactic antibiotics use and resistance in Ethiopia
Samantha Steeman, Maia R. Nofal, Ibrahim Heyredin, Hailemichael Asmamaw, Assefa Tesfaye, Alex Zhuang, Natnael Gebeyehu, Sylvia Bereknyei Merrell, Thomas G. Weiser, Tihitena Negussie Mammo
BMC Health Services Research  vol: 24  issue: 1  year: 2024  
doi: 10.1186/s12913-024-11650-4

30. A comparative study on nosocomial and community-acquired bacterial urinary tract infections: prevalence, antimicrobial susceptibility pattern, and associated risk factors among symptomatic patients attending Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia
Sisay Fekadu, Fitsum Weldegebreal, Tadesse Shumie, Getachew Kabew Mekonnen
Frontiers in Epidemiology  vol: 5  year: 2025  
doi: 10.3389/fepid.2025.1517476

31. An overview of antimicrobial resistance surveillance among healthcare-associated pathogens in South Africa
Ashika Singh-Moodley, Husna Ismail, Olga Perovic
African Journal of Laboratory Medicine  vol: 7  issue: 2  year: 2018  
doi: 10.4102/ajlm.v7i2.741

32. A One Health Approach to Strengthening Antimicrobial Stewardship in Wakiso District, Uganda
David Musoke, Freddy Eric Kitutu, Lawrence Mugisha, Saba Amir, Claire Brandish, Deborah Ikhile, Henry Kajumbula, Ismail Musoke Kizito, Grace Biyinzika Lubega, Filimin Niyongabo, Bee Yean Ng, Jean O’Driscoll, Kate Russell-Hobbs, Jody Winter, Linda Gibson
Antibiotics  vol: 9  issue: 11  first page: 764  year: 2020  
doi: 10.3390/antibiotics9110764

33. Are Antibiotics Prescribed to Inpatients According to Recommended Standard Guidelines in South Sudan? A Retrospective Cross-Sectional Study in Juba Teaching Hospital
Michael E Otim, Desmond Kabuya Demaya, Amina Al Marzouqi, Jean Mukasa
Journal of Multidisciplinary Healthcare  vol: Volume 14  first page: 2871  year: 2021  
doi: 10.2147/JMDH.S321990

34. Strategies and challenges in containing antimicrobial resistance in East Africa: a focus on laboratory-based surveillance
Andrea Molina, Théogène Ihorimbere, Néhémie Nzoyikorera, Eunice Jennifer Nambozo, Saudah Namubiru, Susan Nabadda, Godfrey Pimundu, Susan Mahuro Githii, Gwokpan Awin Nykwe, Abe G. Abias, Felician L. Msigwa, Reuben Ndagula, Nyambura Moremi, Flora Rwanyagatare, Josiane Tuyishimire, Therese Mukankwiro, Noel Gahamanyi, Isabelle Mukagatare, Maike Lamshöft, Julien A. Nguinkal, Emmanuel Achol, Hakim I. Lagu, Eric Nzeyimana, Jürgen May, Florian Gehre, Muna Affara
Antimicrobial Resistance & Infection Control  vol: 14  issue: 1  year: 2025  
doi: 10.1186/s13756-025-01662-y

35. The hospital environment versus carriage: transmission pathways for third-generation cephalosporin-resistant bacteria in blood in neonates in a low-resource country healthcare setting
Dory Kovacs, Vitus Silago, Delfina R. Msanga, Stephen E. Mshana, Jeremiah Seni, Katarina Oravcova, Louise Matthews
Scientific Reports  vol: 12  issue: 1  year: 2022  
doi: 10.1038/s41598-022-11626-6

36. Assessment of General Public’s Knowledge and Opinions towards Antibiotic Use and Bacterial Resistance: A Cross-Sectional Study in an Urban Setting, Rufisque, Senegal
Oumar Bassoum, Ndèye Marème Sougou, Mayassine Diongue, Mamadou Makhtar Mbacke Lèye, Mouhamad Mbodji, Djibril Fall, Ibrahima Seck, Adama Faye, Anta Tal-Dia
Pharmacy  vol: 6  issue: 4  first page: 103  year: 2018  
doi: 10.3390/pharmacy6040103

37. Isolation and Characterization of Antimicrobial-Resistant Escherichia coli from Retail Meats from Roadside Butcheries in Uganda
Torahiko Okubo, Montira Yossapol, Shiori Ikushima, Steven Kakooza, Eddie M. Wampande, Tetsuo Asai, Sayaka Tsuchida, Kenji Ohya, Fumito Maruyama, John D. Kabasa, Kazunari Ushida
Foodborne Pathogens and Disease  vol: 17  issue: 11  first page: 666  year: 2020  
doi: 10.1089/fpd.2020.2796

38. Characterization of Antibiotic Resistance in Select Tertiary Hospitals in Uganda: An Evaluation of 2020 to 2023 Routine Surveillance Data
Jonathan Mayito, Daniel Kibombo, Charles Olaro, Susan Nabadda, Consolata Guma, Immaculate Nabukenya, Andrew Busuge, Flavia Dhikusooka, Alex Andema, Peter Mukobi, Nathan Onyachi, Ben Watmon, Stephen Obbo, Alfred Yayi, James Elima, Celestine Barigye, Filbert J. Nyeko, Ibrahim Mugerwa, Musa Sekamatte, Joel Bazira, Richard Walwema, Mohammed Lamorde, Francis Kakooza, Henry Kajumbula
Tropical Medicine and Infectious Disease  vol: 9  issue: 4  first page: 77  year: 2024  
doi: 10.3390/tropicalmed9040077

39. Guideline Recommendations for Empirical Antimicrobial Therapy: An Appraisal of Research Evidence for Clinical Decision-Making in Ethiopia
Balew Arega, Asnake Agunie, Abraham Minda, Amdemeskel Mersha, Alazar Sitotaw, Getachew Weldeyohhans, Ayele Teshome, Kelemework Adane, Getachew Mengistu
Infectious Diseases and Therapy  vol: 9  issue: 3  first page: 451  year: 2020  
doi: 10.1007/s40121-020-00308-3

40. The contribution of nano‐based strategies in overcoming ceftriaxone resistance: a literature review
Ashagrachew Tewabe, Tesfa Marew, Gebremariam Birhanu
Pharmacology Research & Perspectives  vol: 9  issue: 4  year: 2021  
doi: 10.1002/prp2.849

41. Enrichment of antibiotic resistance genes within bacteriophage populations in saliva samples from individuals undergoing oral antibiotic treatments
Tilde Andersson, Geofrey Makenga, Filbert Francis, Daniel T. R. Minja, Soren Overballe-Petersen, Man-Hung Eric Tang, Kurt Fuursted, Vito Baraka, Rolf Lood
Frontiers in Microbiology  vol: 13  year: 2022  
doi: 10.3389/fmicb.2022.1049110

42. Knowledge, Attitudes, and Practices Regarding Antimicrobial Resistance and Associated Factors Among Healthcare Workers in Addis Ababa, Ethiopia: A Cross‐Sectional Study
Abel Getu, Tesfaye Solomon, Nathan Fikre, Elizabeth Eyasu, Yaregal Fufa, Misgana Tazebachew, Zewdie Aderaw Alemu, Satabdi Datta Choudhury
Canadian Journal of Infectious Diseases and Medical Microbiology  vol: 2025  issue: 1  year: 2025  
doi: 10.1155/cjid/5354292

43. The Prevalence, Patterns, and Trend of Antimicrobial Resistance among Patients at Kumi Orthopaedic Center: A Retrospective Study
John Ekure, Naomi Amuron, Douglas Kilama, Phillip Buluma, Andrew Iloket, Emmanuel Okiring, Samuel Okodi, Faith Akello
Open Journal of Orthopedics  vol: 15  issue: 01  first page: 22  year: 2025  
doi: 10.4236/ojo.2025.151003

44. Community drug retail outlet staff’s knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns
Sewunet Admasu Belachew, Lisa Hall, Linda A. Selvey
Antimicrobial Resistance & Infection Control  vol: 11  issue: 1  year: 2022  
doi: 10.1186/s13756-022-01102-1

45. Widespread antimicrobial resistance among bacterial infections in a Rwandan referral hospital
Tori Sutherland, Christophe Mpirimbanyi, Elie Nziyomaze, Jean-Paul Niyomugabo, Zack Niyonsenga, Claude Mambo Muvunyi, Ariel Mueller, Lisa M. Bebell, Theoneste Nkubana, Emile Musoni, Daniel Talmor, Jennifer Rickard, Elisabeth D. Riviello, Dafna Yahav
PLOS ONE  vol: 14  issue: 8  first page: e0221121  year: 2019  
doi: 10.1371/journal.pone.0221121

46. Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review
Derbew Fikadu Berhe, Getachew Tesfaye Beyene, Berhanu Seyoum, Meseret Gebre, Kassa Haile, Mulugeta Tsegaye, Minyahil Tadesse Boltena, Emawayish Tesema, Taddele Cherinet Kibret, Mulatu Biru, Dawd S. Siraj, Daniel Shirley, Rawleigh Howe, Alemseged Abdissa
Antimicrobial Resistance & Infection Control  vol: 10  issue: 1  year: 2021  
doi: 10.1186/s13756-021-00965-0

47. ‘Some patients demand for a prescription of an antibiotic’: an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda
Mark Kizito, Rejani Lalitha, Henry Kajumbula, Richard Muhumuza, Moses Grace Kintu, David Muyanja, Pauline Byakika-Kibwika
JAC-Antimicrobial Resistance  vol: 6  issue: 6  year: 2024  
doi: 10.1093/jacamr/dlae204

48. Overcoming Bureaucratic Resistance: An Analysis of Barriers to Climate Change Adaptation in South Africa
Nomfundo Patricia Sibiya, Dillip Kumar Das, Coleen Vogel, Sonwabo Perez Mazinyo, Leocadia Zhou, Mukalazi Ahmed Kalumba, Mikateko Sithole, Richard Kwame Adom, Mulala Danny Simatele
Climate  vol: 11  issue: 7  first page: 145  year: 2023  
doi: 10.3390/cli11070145

49. The unequal burden of antimicrobial resistance in Sub-Saharan Africa from 2015 to 2025 with implications for epidemiology, economic impact, and policy
Zuhura I. Kimera, Mecky I. N. Matee
Discover Public Health  vol: 23  issue: 1  year: 2026  
doi: 10.1186/s12982-026-02248-8

50. Antimicrobial Adjuvants - A Novel Approach to Manage Antimicrobial Resistance
Chirag Patel, Sanjeev Acharya, Priyanka Patel
Anti-Infective Agents  vol: 18  issue: 4  first page: 315  year: 2021  
doi: 10.2174/2211352518666200224093739

51. Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: a systematic review
Claudia Truppa, Mahmoud N. Abo-Shehada
BMC Infectious Diseases  vol: 20  issue: 1  year: 2020  
doi: 10.1186/s12879-020-05503-8

52. High Prevalence of Multi-Drug Resistance and Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Among Hospitalized Patients Presumptive for Bacterial Infection at Debre Berhan Comprehensive Specialized Hospital, Ethiopia
Zenawork Sahle, Getabalew Engidaye, Demissew Shenkute, Yeshi Metaferia, Agumas Shibabaw
Infection and Drug Resistance  vol: Volume 15  first page: 2639  year: 2022  
doi: 10.2147/IDR.S363988

53. Ethnobotanical study of nutraceutical plants used to manage opportunistic infections associated with HIV/AIDS in Acholi sub-region, Northern Uganda
Norah Ikinyom, Alice Veronica Lamwaka, Aloysius Tenywa Malagala, Elly Kurobuza Ndyomugyenyi
Tropical Medicine and Health  vol: 51  issue: 1  year: 2023  
doi: 10.1186/s41182-023-00540-w

54. Perceptions of health care workers on involving patients in hand hygiene promotion in selected health facilities of rural and semi-urban districts in Uganda
Fred Twinomugisha, David Musoke, Richard K. Mugambe, John Bosco Isunju, Vicent Kasiita, Henry Kajumbula, Esther Buregyeya
Journal of Infection Prevention  year: 2026  
doi: 10.1177/17571774261450888

55. A systematic review: the current status of carbapenem resistance in East Africa
Kenneth Ssekatawa, Dennis K. Byarugaba, Edward Wampande, Francis Ejobi
BMC Research Notes  vol: 11  issue: 1  year: 2018  
doi: 10.1186/s13104-018-3738-2

56. A systematic review of One Health perspective on the use of antimicrobials in Nigeria
Umulkhairah Onyioiza Arama, Malik Olatunde Oduoye, Bolanle Akanbi-Hakeem, Misha Khan, Polyne Wechuli, Amina Aliyu
CABI One Health  year: 2025  
doi: 10.1079/cabionehealth.2025.0004

57. Antimicrobial resistance surveillance in Ethiopia: Implementation experiences and lessons learned
Rajiha A. Ibrahim, Amete M. Teshal, Surafel F. Dinku, Negga A. Abera, Abebe A. Negeri, Feven G. Desta, Eyasu T. Seyum, Adugna W. Gemeda, Wubshet M. Keficho
African Journal of Laboratory Medicine  vol: 7  issue: 2  year: 2018  
doi: 10.4102/ajlm.v7i2.770

58. High Prevalence of Multidrug-Resistant Enterobacteriaceae Uropathogens Among Outpatients in Rural Southwestern Uganda
Barbra Tuhamize, Deusdedit Tusubira, Charles Masembe, Pascal O Bessong, Frederick Byarugaba, Joel Bazira
Cureus  year: 2025  
doi: 10.7759/cureus.78094

59. Predictors of multi-drug resistance in burn wound colonization following burn injury in a resource-limited setting
Jared R. Gallaher, Wone Banda, Anne M. Lachiewicz, Robert Krysiak, Laura N. Purcell, Anthony G. Charles
Burns  vol: 47  issue: 6  first page: 1308  year: 2021  
doi: 10.1016/j.burns.2020.12.007

60. One Health interventions and challenges under rural African smallholder farmer settings: A scoping review
Evanson R. Omuse, Honest Machekano, Bonoukpoè M. Sokame, Daniel M. Mutyambai, Thomas Dubois, Sevgan Subramanian, Frank Chidawanyika
One Health  vol: 20  first page: 100959  year: 2025  
doi: 10.1016/j.onehlt.2024.100959

61. Appropriate Use of Ceftriaxone in Sub-Saharan Africa: A Systematic Review
Birhanu Meresa Bishaw, Gobezie T Tegegne, Alemseged Beyene Berha
Infection and Drug Resistance  vol: Volume 14  first page: 3477  year: 2021  
doi: 10.2147/IDR.S329996

62. Medical students’ knowledge, attitudes, and motivation towards antimicrobial resistance efforts in Eastern Uganda
Jonathan Babuya, Daniel Waruingi, Douglas Mungujakisa, Osmas Ahimbisibwe, Victoria Ruth Kako, Faith Aporu, Emmanuel Mugume, Julian Nyamupachitu, Kenedy Kiyimba, Yoshito Nishimura
PLOS ONE  vol: 20  issue: 2  first page: e0314250  year: 2025  
doi: 10.1371/journal.pone.0314250

63. Prevalence of antimicrobial resistance in Tanzania: A systematic review and meta-analysis
Charles Basil Kafaiya, Johnson Mshiu, Obadia Bishoge, Jonathan Mcharo, Sia Malekia, Irene Mremi, Angelina M. Lutambi, Mwanaada Kilima, Mary Mayige, Said Aboud, Mabel Kamweli Aworh
PLOS One  vol: 21  issue: 4  first page: e0346433  year: 2026  
doi: 10.1371/journal.pone.0346433

64. A Cross-Sectional Survey of the Knowledge, Attitudes, and Practices of Antimicrobial Users and Providers in an Area of High-Density Livestock-Human Population in Western Kenya
Steven A. Kemp, Gina L. Pinchbeck, Eric M. Fèvre, Nicola J. Williams
Frontiers in Veterinary Science  vol: 8  year: 2021  
doi: 10.3389/fvets.2021.727365

65. Antibiogram signatures of Vibrio species recovered from surface waters in South Western districts of Uganda: Implications for environmental pollution and infection control
Hope Onohuean, Anthony I. Okoh, Uchechukwu U. Nwodo
Science of The Total Environment  vol: 807  first page: 150706  year: 2022  
doi: 10.1016/j.scitotenv.2021.150706

66. Antibiotic Practices, Perceptions and Self-Medication Among Patients at a National Referral Hospital in Uganda
Irene Nabaweesi, Ronald Olum, Arthur Sekite, Willy Suubi, Prossy Nakiwunga, Aron Machali, Richard Kiyumba, Peter Kalyango, Allen Natamba, Yokosofati Igumba, Martin Kyeyune, Harriet Mpairwe, Eric Katagirya
Infection and Drug Resistance  vol: Volume 14  first page: 2155  year: 2021  
doi: 10.2147/IDR.S303075

67. Optical maps of plasmids as a proxy for clonal spread of MDR bacteria: a case study of an outbreak in a rural Ethiopian hospital
Yii-Lih Lin, Tsegaye Sewunet, Sriram KK, Christian G Giske, Fredrik Westerlund
Journal of Antimicrobial Chemotherapy  vol: 75  issue: 10  first page: 2804  year: 2020  
doi: 10.1093/jac/dkaa258

68. Antimicrobial Resistance of Escherichia coli Isolates from Livestock and the Environment in Extensive Smallholder Livestock Production Systems in Ethiopia
Biruk Alemu Gemeda, Barbara Wieland, Gezahegn Alemayehu, Theodore J. D. Knight-Jones, Hiwot Desta Wodajo, Misgana Tefera, Adem Kumbe, Abebe Olani, Shubisa Abera, Kebede Amenu
Antibiotics  vol: 12  issue: 5  first page: 941  year: 2023  
doi: 10.3390/antibiotics12050941

69. Antimicrobial-resistant foodborne pathogens in the Middle East: a systematic review
Abdullah F. Alsayeqh, Amany Hassan Attia Baz, Wageh Sobhy Darwish
Environmental Science and Pollution Research  vol: 28  issue: 48  first page: 68111  year: 2021  
doi: 10.1007/s11356-021-17070-9

70. Antibiotic overuse, poor antimicrobial stewardship, and low specificity of syndromic case management in a cross section of men with urethral discharge syndrome in Kampala, Uganda
Matthew M. Hamill, Annet Onzia, Rosalind M. Parkes-Ratanshi, Peter Kyambadde, Emmanuel Mande, Vivian Nakate, Johan H. Melendez, Ethan Gough, Yukari C. Manabe, Caroline Watts
PLOS ONE  vol: 19  issue: 3  first page: e0290574  year: 2024  
doi: 10.1371/journal.pone.0290574

71. Drug resistance and extended-spectrum β-lactamase (ESBLs) - producing Enterobacteriaceae, Acinetobacter and Pseudomonas species from the views of one-health approach in Ethiopia: a systematic review and meta-analysis
Mengistu Abayneh, Ahmed Zeynudin, Rahel Tamrat, Mulualem Tadesse, Abraham Tamirat
One Health Outlook  vol: 5  issue: 1  year: 2023  
doi: 10.1186/s42522-023-00088-z

72. Magnitude of non-prescribed antibiotic dispensing in Ethiopia: a multicentre simulated client study with a focus on non-urban towns
Sewunet Admasu Belachew, Lisa Hall, Linda A Selvey
Journal of Antimicrobial Chemotherapy  vol: 77  issue: 12  first page: 3462  year: 2022  
doi: 10.1093/jac/dkac341

73. Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: A point prevalence survey
Mark Kizito, Darius Owachi, Falisy Lule, Laura Jung, Vivian Bazanye, Ibrahim Mugerwa, Susan Nabadda, Charles Kabugo, Mabel Kamweli Aworh
PLOS ONE  vol: 20  issue: 1  first page: e0313587  year: 2025  
doi: 10.1371/journal.pone.0313587