Healthcare associated infections and associated antimicrobial resistance in four African countries

Armelle Forrer; Henry Kajumbula; Edward O. Nyarko; Immaculate Barasa; Moses Odhiambo; Argwings Chagwira; Kennedy Abangi; Royce Abisai; Noel Lozani; Jonathan Ngoma; Diana Chiundu; Rosemary Byanyima; Eric Wobudeya; Sam Kalungi; Eric Kwaku Appiah; Maj  Francis Kwame Morgan Tetteh; Patrick Ahiaba; William Asiedu; Janet Midega; Andrew Ian Townsend; Bruce Mark Altevogt; Gemma Buckland-Merrett; Alexandra Passarelli; Naglaa Mohamed; Nicholas Feasey

doi:10.12688/wellcomeopenres.25330.1

Healthcare associated infections and associated antimicrobial resistance in four African countries

Armelle Forrer^*
, Henry Kajumbula
, Edward O. Nyarko
, Immaculate Barasa
, Moses Odhiambo
, Argwings Chagwira
, Kennedy Abangi
, Royce Abisai
, Noel Lozani
, Jonathan Ngoma
, Diana Chiundu
, Rosemary Byanyima
, Eric Wobudeya
, Sam Kalungi
, Eric Kwaku Appiah
, Maj Francis Kwame Morgan Tetteh
, Patrick Ahiaba
, William Asiedu
, Janet Midega
, Andrew Ian Townsend

Bruce Mark Altevogt, Gemma Buckland-Merrett, Alexandra Passarelli, Naglaa Mohamed, Nicholas Feasey

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Background
Healthcare-associated infections (HAIs) significantly contribute to patient morbidity and mortality worldwide, particularly in sub-Saharan Africa (sSA), where prevalence rates range between 6.7% and 28%. HAI are particularly associated with extensive antimicrobial resistance (AMR), which may potentially render HAI untreatable in settings with poor access to Watch and Reserve antibiotics.

Methods
This observational cohort study, conducted across hospitals in Kenya, Ghana, Malawi, and Uganda, aimed to estimate antimicrobial resistance (AMR) rates in HAIs, describe clinical outcomes, and assess hospital length of stay (LoS) among hospitalized patients with HAIs. Kaplan Meir plots were used to explore the impact of treatment adequacy on survival rate for different HAIs. Mixed-effect logistic regression models were used to assess the impact of drug resistance or treatment inadequacy on odds of survival.

Results
Of 336 participants enrolled between October 2021 and January 2023, 207 had at least one positive microbiological test, contributing 244 isolates. The highest AMR prevalence was observed in the Enterobacterales family, Staphylococcus aureus , and Acinetobacter spp. of which 85.3% (116/136), 78.6% (11/14) and 72.7% (16/22) exhibited AMR, respectively. Over 80.9% (114/141) of pathogenic isolates were either 3GC-R or MDR and 88.6% of those (101/114) were both MDR and 3GC-R. There was a 16.7% case fatality rate, with inadequate or unknown adequacy of antimicrobial treatment significantly associated with increased odds of death in patients with bloodstream infection, hospital acquired pneumonia or complicated skin and soft tissue infection (OR 2.90, 95% CI 0.99–8.36). Increased odds of death were also associated with hospital stay in an ICU ward (OR 4.70, 95%CI 1.80–12.32) and with increasing years of age (OR 1.01, 95%CI 1.01–1.04).

Conclusion
The findings highlight the urgent need for local treatment guidelines, improved infection prevention and control measures, and antimicrobial stewardship in sSA to reduce the burden of AMR and improve patient outcomes.

Original language	English
Article number	272
Number of pages	1
Journal	Wellcome Open Research
Volume	11
DOIs	https://doi.org/10.12688/wellcomeopenres.25330.1
Publication status	Submitted - 11 May 2026

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Forrer, A., Kajumbula, H., Nyarko, E. O., Barasa, I., Odhiambo, M., Chagwira, A., Abangi, K., Abisai, R., Lozani, N., Ngoma, J., Chiundu, D., Byanyima, R., Wobudeya, E., Kalungi, S., Appiah, E. K., Tetteh, M. F. K. M., Ahiaba, P., Asiedu, W., Midega, J., ... Feasey, N. (2026). Healthcare associated infections and associated antimicrobial resistance in four African countries. Manuscript submitted for publication. https://doi.org/10.12688/wellcomeopenres.25330.1

@article{c5b503adbe914c03b8c7fd90be9a950a,

title = "Healthcare associated infections and associated antimicrobial resistance in four African countries",

abstract = "Background Healthcare-associated infections (HAIs) significantly contribute to patient morbidity and mortality worldwide, particularly in sub-Saharan Africa (sSA), where prevalence rates range between 6.7\% and 28\%. HAI are particularly associated with extensive antimicrobial resistance (AMR), which may potentially render HAI untreatable in settings with poor access to Watch and Reserve antibiotics. Methods This observational cohort study, conducted across hospitals in Kenya, Ghana, Malawi, and Uganda, aimed to estimate antimicrobial resistance (AMR) rates in HAIs, describe clinical outcomes, and assess hospital length of stay (LoS) among hospitalized patients with HAIs. Kaplan Meir plots were used to explore the impact of treatment adequacy on survival rate for different HAIs. Mixed-effect logistic regression models were used to assess the impact of drug resistance or treatment inadequacy on odds of survival. Results Of 336 participants enrolled between October 2021 and January 2023, 207 had at least one positive microbiological test, contributing 244 isolates. The highest AMR prevalence was observed in the Enterobacterales family, Staphylococcus aureus , and Acinetobacter spp. of which 85.3\% (116/136), 78.6\% (11/14) and 72.7\% (16/22) exhibited AMR, respectively. Over 80.9\% (114/141) of pathogenic isolates were either 3GC-R or MDR and 88.6\% of those (101/114) were both MDR and 3GC-R. There was a 16.7\% case fatality rate, with inadequate or unknown adequacy of antimicrobial treatment significantly associated with increased odds of death in patients with bloodstream infection, hospital acquired pneumonia or complicated skin and soft tissue infection (OR 2.90, 95\% CI 0.99–8.36). Increased odds of death were also associated with hospital stay in an ICU ward (OR 4.70, 95\%CI 1.80–12.32) and with increasing years of age (OR 1.01, 95\%CI 1.01–1.04). Conclusion The findings highlight the urgent need for local treatment guidelines, improved infection prevention and control measures, and antimicrobial stewardship in sSA to reduce the burden of AMR and improve patient outcomes.",

author = "Armelle Forrer and Henry Kajumbula and Nyarko, \{Edward O.\} and Immaculate Barasa and Moses Odhiambo and Argwings Chagwira and Kennedy Abangi and Royce Abisai and Noel Lozani and Jonathan Ngoma and Diana Chiundu and Rosemary Byanyima and Eric Wobudeya and Sam Kalungi and Appiah, \{Eric Kwaku\} and Tetteh, \{Maj Francis Kwame Morgan\} and Patrick Ahiaba and William Asiedu and Janet Midega and Townsend, \{Andrew Ian\} and Altevogt, \{Bruce Mark\} and Gemma Buckland-Merrett and Alexandra Passarelli and Naglaa Mohamed and Nicholas Feasey",

note = "Funding: This work was supported by Wellcome grant 226473; Pfizer Inc. study code X9001276. This study was conducted as part of a Surveillance Partnership to Improve Data for Action on Antimicrobial Resistance (SPIDAAR) programme. SPIDAAR is a public-private research collaboration between Pfizer Inc, Wellcome Trust and the governments of Ghana, Kenya, Malawi and Uganda to track resistance patterns and better understand the burden of antimicrobial resistance (AMR) on patients living in low- and middle-income countries. Medical writing support for this manuscript, under the direction of the authors, was supported by Wellcome (grant 226473) and undertaken in accordance with Good Publication Practice (GPP 2022) guidelines (Ann Intern Med 2022; 175: 1298–1304).",

year = "2026",

month = may,

day = "11",

doi = "10.12688/wellcomeopenres.25330.1",

language = "English",

volume = "11",

journal = "Wellcome Open Research",

issn = "2398-502X",

publisher = "F1000 Research Ltd.",

}

Forrer, A, Kajumbula, H, Nyarko, EO, Barasa, I, Odhiambo, M, Chagwira, A, Abangi, K, Abisai, R, Lozani, N, Ngoma, J, Chiundu, D, Byanyima, R, Wobudeya, E, Kalungi, S, Appiah, EK, Tetteh, MFKM, Ahiaba, P, Asiedu, W, Midega, J, Townsend, AI, Altevogt, BM, Buckland-Merrett, G, Passarelli, A, Mohamed, N & Feasey, N 2026, 'Healthcare associated infections and associated antimicrobial resistance in four African countries', Wellcome Open Research, vol. 11, 272. https://doi.org/10.12688/wellcomeopenres.25330.1

TY - JOUR

T1 - Healthcare associated infections and associated antimicrobial resistance in four African countries

AU - Forrer, Armelle

AU - Kajumbula, Henry

AU - Nyarko, Edward O.

AU - Barasa, Immaculate

AU - Odhiambo, Moses

AU - Chagwira, Argwings

AU - Abangi, Kennedy

AU - Abisai, Royce

AU - Lozani, Noel

AU - Ngoma, Jonathan

AU - Chiundu, Diana

AU - Byanyima, Rosemary

AU - Wobudeya, Eric

AU - Kalungi, Sam

AU - Appiah, Eric Kwaku

AU - Tetteh, Maj Francis Kwame Morgan

AU - Ahiaba, Patrick

AU - Asiedu, William

AU - Midega, Janet

AU - Townsend, Andrew Ian

AU - Altevogt, Bruce Mark

AU - Buckland-Merrett, Gemma

AU - Passarelli, Alexandra

AU - Mohamed, Naglaa

AU - Feasey, Nicholas

N1 - Funding: This work was supported by Wellcome grant 226473; Pfizer Inc. study code X9001276. This study was conducted as part of a Surveillance Partnership to Improve Data for Action on Antimicrobial Resistance (SPIDAAR) programme. SPIDAAR is a public-private research collaboration between Pfizer Inc, Wellcome Trust and the governments of Ghana, Kenya, Malawi and Uganda to track resistance patterns and better understand the burden of antimicrobial resistance (AMR) on patients living in low- and middle-income countries. Medical writing support for this manuscript, under the direction of the authors, was supported by Wellcome (grant 226473) and undertaken in accordance with Good Publication Practice (GPP 2022) guidelines (Ann Intern Med 2022; 175: 1298–1304).

PY - 2026/5/11

Y1 - 2026/5/11

N2 - Background Healthcare-associated infections (HAIs) significantly contribute to patient morbidity and mortality worldwide, particularly in sub-Saharan Africa (sSA), where prevalence rates range between 6.7% and 28%. HAI are particularly associated with extensive antimicrobial resistance (AMR), which may potentially render HAI untreatable in settings with poor access to Watch and Reserve antibiotics. Methods This observational cohort study, conducted across hospitals in Kenya, Ghana, Malawi, and Uganda, aimed to estimate antimicrobial resistance (AMR) rates in HAIs, describe clinical outcomes, and assess hospital length of stay (LoS) among hospitalized patients with HAIs. Kaplan Meir plots were used to explore the impact of treatment adequacy on survival rate for different HAIs. Mixed-effect logistic regression models were used to assess the impact of drug resistance or treatment inadequacy on odds of survival. Results Of 336 participants enrolled between October 2021 and January 2023, 207 had at least one positive microbiological test, contributing 244 isolates. The highest AMR prevalence was observed in the Enterobacterales family, Staphylococcus aureus , and Acinetobacter spp. of which 85.3% (116/136), 78.6% (11/14) and 72.7% (16/22) exhibited AMR, respectively. Over 80.9% (114/141) of pathogenic isolates were either 3GC-R or MDR and 88.6% of those (101/114) were both MDR and 3GC-R. There was a 16.7% case fatality rate, with inadequate or unknown adequacy of antimicrobial treatment significantly associated with increased odds of death in patients with bloodstream infection, hospital acquired pneumonia or complicated skin and soft tissue infection (OR 2.90, 95% CI 0.99–8.36). Increased odds of death were also associated with hospital stay in an ICU ward (OR 4.70, 95%CI 1.80–12.32) and with increasing years of age (OR 1.01, 95%CI 1.01–1.04). Conclusion The findings highlight the urgent need for local treatment guidelines, improved infection prevention and control measures, and antimicrobial stewardship in sSA to reduce the burden of AMR and improve patient outcomes.

AB - Background Healthcare-associated infections (HAIs) significantly contribute to patient morbidity and mortality worldwide, particularly in sub-Saharan Africa (sSA), where prevalence rates range between 6.7% and 28%. HAI are particularly associated with extensive antimicrobial resistance (AMR), which may potentially render HAI untreatable in settings with poor access to Watch and Reserve antibiotics. Methods This observational cohort study, conducted across hospitals in Kenya, Ghana, Malawi, and Uganda, aimed to estimate antimicrobial resistance (AMR) rates in HAIs, describe clinical outcomes, and assess hospital length of stay (LoS) among hospitalized patients with HAIs. Kaplan Meir plots were used to explore the impact of treatment adequacy on survival rate for different HAIs. Mixed-effect logistic regression models were used to assess the impact of drug resistance or treatment inadequacy on odds of survival. Results Of 336 participants enrolled between October 2021 and January 2023, 207 had at least one positive microbiological test, contributing 244 isolates. The highest AMR prevalence was observed in the Enterobacterales family, Staphylococcus aureus , and Acinetobacter spp. of which 85.3% (116/136), 78.6% (11/14) and 72.7% (16/22) exhibited AMR, respectively. Over 80.9% (114/141) of pathogenic isolates were either 3GC-R or MDR and 88.6% of those (101/114) were both MDR and 3GC-R. There was a 16.7% case fatality rate, with inadequate or unknown adequacy of antimicrobial treatment significantly associated with increased odds of death in patients with bloodstream infection, hospital acquired pneumonia or complicated skin and soft tissue infection (OR 2.90, 95% CI 0.99–8.36). Increased odds of death were also associated with hospital stay in an ICU ward (OR 4.70, 95%CI 1.80–12.32) and with increasing years of age (OR 1.01, 95%CI 1.01–1.04). Conclusion The findings highlight the urgent need for local treatment guidelines, improved infection prevention and control measures, and antimicrobial stewardship in sSA to reduce the burden of AMR and improve patient outcomes.

U2 - 10.12688/wellcomeopenres.25330.1

DO - 10.12688/wellcomeopenres.25330.1

M3 - Article

SN - 2398-502X

VL - 11

JO - Wellcome Open Research

JF - Wellcome Open Research

M1 - 272

ER -

Healthcare associated infections and associated antimicrobial resistance in four African countries

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