Twelve African and German University Hospitals partner to tackle Antimicrobial Resistance (AMR)
With the help of an innovative app, and through mutual learning, a hospital partnership network has improved how its members collect and use AMR data.
At the University Medical Center in Jimma, Ethiopia, a laboratory technician peers at a sample of bacteria taken from a man with a history of lung disease who has been admitted to hospital for recurrent pneumonia. What she sees in her laboratory in the teaching hospital is alarming. This bacterium causing the fever is Klebsiella pneumoniae – it is invading his body. The doctors at the hospital collect all the bags of Meropenem (a very costly antibiotic) that they have received as ‘freebies’ from sales representatives of pharmaceutical companies to treat him. He is fortunate and survives. However, the solution doctors found for him cannot work at scale – many other patients in his situation died and will continue to die.
In Ethiopia and other low or lower middle-income countries, the most effective antibiotics are not always available, or affordable. This is one of the reasons why untreatable bacterial infections are on the rise across the globe: Experts warn that we have entered the “post-antibiotic era” in which hundreds of thousands will suffer and die each year from infections that were once easily controlled with antibiotics. This new article on our portal provides a detailed overview of the AMR challenge. In what follows, we present one of Germany’s contributions to supporting its partners in Sub-Saharan Africa in combating it.
‘There is no more serious issue than AMR. HIV is not as serious, Covid-19 is not as serious, tuberculosis is not as serious – this is worse than anything we have ever witnessed,’ warns Professor Esayas Gudina, a consultant physician at Jimma University in Ethiopia.
Three reasons for the steady increase of AMR in Sub-Saharan Africa
It is estimated that AMR kills more than three hundred thousand people per year in Sub-Saharan Africa (Lancet, 2022). Specialists who are trying to tackle this challenge are aware of the complex reasons behind it:
Firstly, ‘AMR has a lot to do with the way antibiotics are over-used in hospitals, in agriculture and in veterinary medicine. We need policies that take account of and control the use of antibiotics in all these sectors,’ says Dr Jules Ndoli who Head’s the Clinical Education & Research Division at the University Teaching Hospital of Butare (CHUB) in Rwanda.
Secondly, at the hospital level, while bad prescription practices of antibiotics is one driver, there are many others, such as poor infection control practices; supply of poor-quality antibiotics; lack of adequate diagnostics and surveillance; and insufficient patient education provided by clinicians, to mention just a few. ‘We have a very, very short supply of antibiotics in terms of the quality, in terms of the quantity, and in terms of the type,’ says Professor Gudina. In addition, he is aware of the lack of access to second and third-line antibiotics that are effective against resistant strains. According to him ‘these more sophisticated antibiotics are reserved for the rich – those who can buy from the private pharmacy.’
Thirdly, according to Dr Arne Kroidl, a specialist in internal medicine and infectious diseases at the Ludwig-Maximilians-Universität University Hospital in Munich, there are not enough laboratories in Africa’s hospitals that can quickly and reliably identify drug-resistant bacteria: ‘To make informed treatment decisions right at the bedside, doctors need this information, and they need it fast.’
The birth of the COMBAT AMR in Africa network
From 2016 until July 2022, the University and Hospital Partnerships in Africa (HKP) project, implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the Federal German Ministry for Economic Cooperation and Development (BMZ) worked to improve quality of healthcare through partnership projects between some of the most prestigious university hospitals in Africa and in Germany. It quickly became clear to all involved that tackling AMR was one important way to achieve this objective.
In the first year, and without knowing about the contents of each other’s funding requests, six German hospitals and their six African partner hospitals applied to HKP for funding for AMR-related activities. HKP advisors proposed that they join forces, which they did: the COMBAT AMR in Africa Network (Comprehensive Multi-Centre Bioinformatics-based Action to Tackle AMR in sub-Saharan Africa) was born. As illustrated in the group photo below, the multi-partner network brought together African clinicians and infectious disease specialists from Rwanda, Ethiopia, Ghana, Kenya and Uganda, alongside their German counterparts in Düsseldorf, Munich, Berlin, Frankfurt, Leipzig and Hamburg to develop an AMR surveillance platform for the exchange of data, knowledge and experiences. From 2016 to 2019, the project strengthened laboratory capacity and trained lab technicians in the African partner sites to identify bacteria causing infections through scientific dialogue, training and repeated exchange visits back and forth between the partnering hospitals and facilities in Africa and Germany.
Improving laboratory capacities is not enough
According to Professor Gudina, however, training lab technicians and upgrading the laboratory facilities with the latest diagnostic equipment did little to incentivise the physicians to use the lab services: ‘What we found was that physicians’ utilisation of the new blood culture services was not at all at the level we had expected. In other cases, the cultures were requested and performed by the labs yet the results were not claimed at all’. In the meantime, patients were on unnecessary or ineffective courses of antibiotics, or left the hospital without treatment. To change this, the COMBAT AMR network decided to use the second HKP funding period, 2019 to 2022, to develop a digital information system for AMR data gathered during routine patient care at each of the six partnership sites. One objective was to move from paper-based to digital communication so that ‘the results reach the physicians as soon as they are available,’ says Professor Gudina. It was hoped that this would motivate clinicians to send more samples to the laboratory instead of treating patients without blood culture-based diagnosis. Each sample or swab represents a patient for whom the culprit bacterium needs to be identified to know which antibiotic it will respond to.
A DHIS2-based app that works for all sites
‘The idea was to produce an app that links labs and clinicians and fits into all existing information systems,’ says Dr Kroidl. Given that the different hospitals in the network already worked with various laboratory information systems it was important to find a digital solution that would be interoperable with all of them and allow for continuous improvements. The global digital good District Health Information Software 2 (DHIS2), already in use in all the health systems of the network, seemed the best option.
HISP India (Society for Health Information Systems Programmes), a not-for-profit NGO with more than a decade of experience in applying e-health solutions for the public health sector, was commissioned to develop the DHIS2 mobile app according to all partners’ needs and requirements. ‘We started with a similar app that we are already using here in India. The hospital partners then told us what they would like us to adjust, and why, and we would modify the app accordingly,’ says Professor Sundeep Sahay, Founder of HISP India and Professor of Informatics at the University of Oslo. ‘The app allows clinicians to access all patient data: which tests have been done, which results are pending and which are available,’ says Dr Gitika Arora, a Senior Advisor at HISP India who worked with the local teams to fine-tune the digital app. Once lab results are available they are pushed to the Android-based mobile app so that clinicians can access them also when offline. The application can be used on tablets and smartphones as well as on desktop computers and laptops.
What did the network achieve?
The DHIS2 app has been configured and is already in use in the partner hospitals in Ethiopia and in Rwanda (see figure above). In Ghana, Kenya and Uganda the local teams are still working on different hurdles before they can be trained and start using the app, but in principle it is ready for launching there, too. Local HISP teams exist in the three countries and are available to provide training and backstopping when called upon.
According to Dr Kroidl ‘staff from all partner hospitals in our network showed a lot of initiative in our regular calls. They worked hard towards addressing AMR and towards e-health solutions. COVID-19 did not change this, on the contrary, it boosted research productivity!’
As first pilot site for the app, Ethiopia’s Jimma University Medical Center hospital carefully monitored how many bacteria cultures clinicians requested after the app was introduced. The monthly average stood at 184 cultures, compared to 83 prior to the digital intervention, which is a clear success! However, even if cultures are ordered this does not mean that prescription practices have improved – evaluating this will be the next step for the team in Jimma.
‘We must not lose this fight’
For Dr Kroidl the introduction of the app has just been the beginning. Next, he thinks the network should use the AMR data that it generates to examine which resistant strains of bacteria are prominent so as to ensure that the correct way of diagnosing and treating them is addressed in keeping with the respective national AMR guidelines: ‘In the future, the app could do more than facilitating fast communication between clinicians and labs. It could also serve as a surveillance and research tool, supporting clinical decision-making based on the evidence on resistant strains and their treatment that it gathered over e.g. the past six months. This would be an important contribution to partner countries’ antibiotic stewardship.’
The HKP project and the COMBAT AMR network have shown that it is possible for institutional partnerships to spur innovation and mutual learning for improved healthcare in Africa. In the view of Professor Gudina, this is the kind of collaborative action the world now needs to rise to the AMR challenge: ‘Antibiotics are just too important for us – we must not lose this fight. Look what we achieved with our partnership network: Where there is a will there is a way!’