National AMR context
In Rwanda, antimicrobial resistance (AMR) is driven by inappropriate use of and uncontrolled access to antibiotics, weak regulation and oversight, and poor clinical diagnostic capacity, highlighting the urgent need for antimicrobial stewardship for surgical antibiotic prophylaxis in Rwanda. A study from one of the country’s largest hospitals found that many common bacteria were resistant to widely used antibiotics. Fewer than one in three infections could be treated with ceftriaxone, almost none responded to co-amoxiclav, and less than half were treatable with ciprofloxacin (1). At the same hospital, a point prevalence survey (PPS) of antimicrobial prescriptions was conducted and found that there was an inappropriate use of antimicrobials, including the high usage of watch antibiotics (~65%) across the hospital and the inappropriate use of antibiotics for surgical antibiotic prophylaxis (SAP) in ~83% of patients (2). In Rwanda, AMR-related deaths accounted for 2,400 of the country’s 9,800 deaths in 2019, and among the 204 assessed nations, Rwanda has the 34th-highest age-standardised mortality rate per 100,000 people linked to AMR (3).
Problem
Surgical Site Infections (SSIs) are one of the leading contributors to postoperative deaths (4, 5). They represent 20% of all hospital-acquired infections, extend the duration of hospital stays, raise the risk of postoperative mortality by two to eleven times, and result in significant financial costs for both healthcare providers and patients (6,7). A review from a major public teaching hospital in Rwanda found that about 11% of surgical patients developed an SSI, and many of the bacteria causing these infections were resistant to commonly used antibiotics (8). Surgical Antibiotic Prophylaxis (SAP) can help prevent SSIs by reducing bacteria at the surgical site during the operative procedure. Many SSIs are caused by the endogenous translocation of the patient’s intestinal microbiota (9). Implementation of SAP guidelines in Rwanda is limited. Challenges include low awareness and understanding of the guidelines, poor adherence, limited collaboration between health professionals, difficulties adapting international guidelines to local conditions, shortages of recommended antibiotics, and weak systems to monitor SSIs and AMR.
Project overview
To address these challenges and to adhere to the Rwanda National Action Plan on AMR (NAP 2.0), this project aims to develop and evaluate a feasible approach to antimicrobial stewardship (AMS) for SAP, alongside key infection prevention and control (IPC) practices, in four Rwandan hospitals by assessing baseline practices and implementing training, monitoring, and feedback to improve SAP guideline adherence to at least 80% within 12 months, with evidence generated to inform national decision-making and support policy uptake for broader implementation.
In phase I (the first 10 months) the project will focus on measuring baseline surveillance to assess antibiotic use for SAP, IPC practices, SSI rates, major pathogen resistance profiles. Further capacity strengthening for AMS will be conducted, and the roles and involvement of key stakeholders will be mapped.
Intended outcomes
- Improved SAP guideline adherence to at least 80% within 12 months.
- Reduced incidence of SSI, including earlier detection and improved clinical outcomes such as shorter hospital stays and fewer readmissions and reoperations.
- Improved understanding of pathogens causing SSIs and their AMR patterns to inform targeted prevention and treatment strategies.
- Strengthened institutional and stakeholder capacity for effective SAP and AMS implementation.
- Increased equity and sustainability of SAP and AMS implementation through identification and mitigation of financial, system-level, and access-related barriers.
References
1. Bizimungu O, Crook P, Babane JF, Bitunguhari L. The prevalence and clinical context of antimicrobial resistance amongst medical inpatients at a referral hospital in Rwanda: a cohort study. Antimicrob Resist Infect Control. 2024;13(1).
2. Igizeneza A, Bitunguhari L, Masaisa F, et al. Prescription practices and usage of antimicrobials in a tertiary teaching hospital in Rwanda: a call for antimicrobial stewardship. Antibiotics (Basel). 2024;13(11):1032.
3. Institute for Health Metrics and Evaluation (IHME). The burden of antimicrobial resistance (AMR) in Rwanda. 2019;1–4. Available from: https://www.healthdata.org/sites/default/files/2023-09/Rwanda.pdf.
4. Nepogodiev D, et al. Global burden of postoperative death. Lancet. 2019.
5. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59–74.
6. Jenks PJ, Laurent M, McQuarry S, et al. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect. 2014;86(1):24–33.
7. Koek MBG, van Lieshout EMM, van Ramshorst B, et al. Burden of surgical site infections in the Netherlands: cost analyses and disability-adjusted life years. J Hosp Infect. 2019;101(2):192–198.
8. Mukagendaneza MJ, Munyaneza E, Muhawenayo E, et al. Incidence, root causes, and outcomes of surgical site infections in a tertiary care hospital in Rwanda: a prospective observational cohort study. Patient Saf Surg. 2019;13:10.
9. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S51–61.
