National AMR context
Antimicrobial resistance (AMR) is a growing public health threat in Uganda, with significant implications for patient safety, healthcare costs, and the effectiveness of modern medical care. Recent estimates indicate that over 7,000 deaths annually are directly attributable to AMR, with many more associated deaths linked to resistant infections. Within hospital settings, particularly surgical wards, the burden is amplified by high infection rates and widespread antimicrobial misuse.
Uganda has made substantial progress in strengthening AMR governance through the National Action Plan on AMR, supported by improved laboratory capacity, surveillance systems, and national coordination structures. However, a critical gap remains between policy and practice. Infection prevention and control (IPC) systems are inconsistently implemented, and antimicrobial stewardship (AMS) practices, especially surgical antibiotic prophylaxis (SAP), often deviate from guidelines.
Evidence from Regional Referral Hospitals shows that nearly all surgical patients receive antibiotics for longer than recommended durations, increasing antimicrobial selection pressure. At the same time, microbiological data indicate rising resistance among common surgical pathogens.
This context highlights the urgent need for implementation-focused solutions that translate existing policies, surveillance data, and guidelines into effective, routine clinical practice.
Problem
Surgical site infections (SSIs) remain a major cause of preventable morbidity in Uganda, particularly within Regional Referral Hospitals. These infections are driven by two interconnected system failures: weak IPC practices and inappropriate use of SAP.
IPC systems are inconsistently implemented due to gaps in training, limited resources, weak audit and feedback mechanisms, and misalignment with routine clinical workflows. As a result, perioperative environments remain vulnerable to pathogen transmission. At the same time, SAP practices frequently deviate from evidence-based standards. Nearly all surgical patients receive antibiotics for prolonged periods beyond recommended 24-hour limits, often without microbiological guidance.
These two failures interact to sustain high SSI rates, increase unnecessary antibiotic exposure, and accelerate the emergence of antimicrobial resistance. The consequences include prolonged hospital stays, higher healthcare costs, increased patient financial burden, and poorer clinical outcomes.
Despite strong national AMR policies and improved surveillance systems, there is limited evidence on how to effectively implement integrated IPC and SAP interventions within real-world hospital settings in Uganda. This project addresses this critical gap by testing practical, scalable solutions that target both infection transmission and antimicrobial use simultaneously.
Project overview
This project will implement and evaluate an integrated intervention combining a WHO-aligned IPC care bundle with facility-specific SAP protocols in three Regional Referral Hospitals: Arua, Jinja, and Kabale.
The study will employ a phased implementation research design consisting of baseline assessment, intervention, and evaluation phases. The baseline phase will generate a comprehensive understanding of SSI burden, antimicrobial resistance patterns, behavioural drivers, and health system constraints using clinical surveillance, microbiological analysis, and behavioural frameworks such as COM-B and CFIR.
The intervention phase will introduce a multimodal IPC care bundle, including hand hygiene, aseptic technique, environmental cleaning, and governance strengthening, alongside locally adapted SAP protocols addressing antibiotic choice, timing, dosing, and duration. These interventions will be supported by training, mentorship, audit and feedback, and routine surveillance systems.
The project will integrates clinical epidemiology, behavioural science, microbiology, and health economics to assess effectiveness, feasibility, acceptability, and cost-effectiveness. By embedding interventions within routine hospital systems, the study aims to generate implementation-ready evidence that can inform national policy and scale-up strategies.
Intended outcomes
The project aims to achieve measurable improvements in both clinical outcomes and health system performance. The primary outcome will be a reduction in the incidence of surgical site infections among patients undergoing surgery in participating hospitals. This will be accompanied by improved adherence to evidence-based IPC practices and more appropriate use of surgical antibiotic prophylaxis.
At the antimicrobial level, the project will reduce unnecessary antibiotic exposure, including prolonged prophylaxis, thereby decreasing antimicrobial selection pressure and contributing to AMR containment. Improvements in prescribing practices will be guided by facility-specific protocols aligned with local resistance patterns.
From a health system perspective, the project will strengthen IPC and antimicrobial stewardship structures, enhance use of microbiology data in clinical decision-making, and establish sustainable audit and feedback mechanisms. Economic evaluation will generate evidence on cost-effectiveness and budget impact, supporting efficient resource allocation.
At the national level, findings will be translated into policy briefs, implementation toolkits, and a costed roadmap for scale-up. The project is expected to inform updates to national IPC and SAP guidelines and contribute to Uganda’s broader AMR containment strategy. Ultimately, it will provide a scalable model for improving surgical safety and antibiotic use in low-resource settings.
