National AMR Context
Antimicrobial resistance is an increasing One Health challenge in the Democratic Republic of the Congo, driven by inappropriate antimicrobial use, weak sanitation and wastewater infrastructure, and limited environmental AMR surveillance. The DRC has implemented a National Action Plan on AMR since 2018, which recognises irrational antimicrobial use, environmental dissemination of resistant bacteria and antimicrobial residues, limited diagnostic capacity, gaps in regulation and inadequate management of hospital waste and wastewater as priority concerns. In Kinshasa, hospital wastewater and urban sewage may be discharged into receiving environments without adequate treatment, creating potential reservoirs and pathways for antimicrobial-resistant bacteria and resistance genes. Although national efforts are strengthening AMR surveillance and rational antimicrobial use, evidence on multidrug-resistant Gram-negative bacteria in non-clinical environments remains scarce. In particular, the contribution of hospital effluents to environmental dissemination of ESBL- and carbapenemase-producing Enterobacterales is insufficiently characterised, limiting the evidence available for targeted policy and intervention design.
Problem
Hospital wastewater may act as an important reservoir and transmission pathway for antimicrobial-resistant bacteria in Kinshasa, yet there is limited local evidence on the occurrence, distribution and environmental dissemination of clinically important multidrug-resistant Gram-negative bacteria. At the same time, inappropriate antimicrobial prescribing and weaknesses in healthcare waste and wastewater management may amplify selection and release of resistant organisms. These interconnected problems are recognised within the DRC National Action Plan on AMR, but insufficient quantitative and behavioural data are available to determine the scale of the risk or prioritise practical interventions. The project addresses this gap by assessing resistant bacteria in wastewater from selected hospitals and examining healthcare workers’ knowledge, attitudes and practices related to antibiotic prescribing and wastewater management. Integrating microbiological, environmental and socio-behavioural evidence will help identify institutional and operational gaps that can be addressed through future antimicrobial stewardship, infection prevention, wastewater treatment and regulatory interventions.
Project overview
This pilot cross-sectional mixed-methods study will assess environmental dissemination of multidrug-resistant bacteria through hospital wastewater and antimicrobial prescription practices in Kinshasa. Wastewater samples will be collected from six healthcare facilities representing different wastewater-management systems. Laboratory investigations will characterise multidrug-resistant Gram-negative bacteria, with particular attention to ESBL- and carbapenemase-producing Enterobacterales and resistance to beta-lactam and carbapenem antibiotics. The microbiological work will be complemented by quantitative and qualitative assessment of healthcare workers’ knowledge, attitudes and practices regarding antimicrobial prescribing, healthcare waste and wastewater management. Environmental, microbiological and socio-behavioural findings will be integrated to identify critical risks and priority intervention areas. ACOREP will coordinate implementation with INRB, the University of Kinshasa, LASE and external technical partners, within a governance structure linked to national AMR coordination.
“This project provides us with a first snapshot of the dissemination of resistant bacteria in Kinshasa through hospital wastewater discharged into the environment. The results we obtain will enable us to guide appropriate interventions for effective environmental surveillance of AMR, as well as future actions for proper wastewater management and the rational use of antimicrobials aimed at limiting the spread of AMR.” – Project PI, Democratic Republic of the Congo
Intended outcomes
The project will provide baseline evidence on the prevalence and distribution of multidrug-resistant Gram-negative bacteria in hospital wastewater from selected Kinshasa healthcare facilities, together with information on wastewater-management practices and healthcare workers’ antimicrobial prescribing and waste-management behaviours. Integrated analysis will identify critical institutional, operational and environmental gaps and strengthen understanding of hospital wastewater as an AMR reservoir. The findings are expected to strengthen environmental AMR surveillance and inform hospital wastewater management guidance, antimicrobial stewardship, infection prevention measures and policy development. They will also guide future intervention and implementation research, including assessment of improved hospital waste-management practices, local wastewater filtration or treatment technologies, and strengthened regulatory approaches. Results will be shared through technical reports, the National AMR Coordination Committee, stakeholder workshops, policy dialogues and scientific publications to support evidence-based decision-making and resource mobilisation.
About the Team Europe Initiative
This project is funded through the Team Europe Initiative (TEI) Action on Fighting Antimicrobial Resistance and Strengthening the One Health Workforce in Africa, a collaborative effort to support locally led, evidence-informed action on antimicrobial resistance (AMR) across the continent. Through work on AMR mitigation, implementation research, workforce development, health economics, and One Health, the initiative aims to strengthen capacity and generate practical, context-specific approaches that can support sustainable AMR action in African countries.
