Antimicrobial Susceptibility Testing Capacity in Selected Private Hospitals of Western Uganda, May–June, 2025

Summery

Background: Antimicrobial resistance (AMR) poses a major public health threat globally, with bacterial AMR contributing to millions of deaths annually, disproportionately affecting low- and middle-income countries like Uganda. Reliable antimicrobial susceptibility testing (AST) is essential for guiding therapy, supporting stewardship, and informing surveillance. However, laboratory capacity remains limited in many settings, particularly in private hospitals, which play a significant role in healthcare delivery. We assessed the AST capacity in private hospitals in Western Uganda to identify gaps and inform integration into Uganda’s national AMR response framework.

Methods: We conducted a cross-sectional assessment from May to June 2025 in three purposively selected private hospitals in Western Uganda (A and B in Mbarara District; C in Kabale District) with functional microbiology units. Data were collected using the US Centers for Disease Control and Prevention-validated Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool, a self-scoring questionnaire with 15 modules covering infrastructure, human resources, quality assurance, organism identification, AST methods, panels, and data management. Four staff per hospital (manager, quality officer, bench personnel) responded. Scores ranged 0–100%, classified as low (0–49%), moderate (50–79%), or good (80–100%). Overall capacity was the average of module scores.

Results: The three laboratories had an overall average AST capacity of 53%. B scored highest at 61% (moderate), while A and C scored 49% each (low); none reached good capacity. Seven modules scored below 50%: identification methods (31%), AST quality control (34%), AST panels/policy/analysis (36%), overall quality control (43%), AST expert rules (46%), and processing (48%). These gaps compromised result reliability and surveillance utility.

Conclusion: Private hospitals in Western Uganda exhibit moderate-to-low AST capacity, with critical deficiencies in identification, quality control, and interpretive rules, consistent with regional challenges. Targeted interventions prioritizing training, standardized tools, reagent supply, laboratory information systems, and integration into national surveillance are essential to enhance readiness, support Uganda’s NAP-AMR II, reduce empirical prescribing, and strengthen AMR containment in resource-limited settings.

Background

Antimicrobial resistance (AMR) is a major global public health threat that compromises the prevention and treatment of infectious diseases and was directly associated with approximately 1.27 million deaths in 2022 (1-3). The burden is greatest in low- and middle-income countries (LMICs), including Uganda, where health systems face limitations in diagnostic capacity, surveillance, antimicrobial regulation, data quality, digitalization, and resource availability (4, 5). Antimicrobial susceptibility testing (AST) is critical for guiding treatment, supporting antimicrobial stewardship, and generating AMR surveillance data, but its reliability depends on trained personnel, standardized procedures, quality systems, and appropriate laboratory infrastructure (6, 7).

Despite its importance, AST capacity in many LMICs remains constrained by inadequate infrastructure, limited skilled staff, inconsistent supplies, and weak quality management systems, leading to greater reliance on empirical treatment and accelerating AMR (8, 9). Although Uganda has strengthened AMR response efforts through national policies and surveillance initiatives, evidence on the capacity of private hospital laboratories to provide quality-assured AST remains limited(10). We assessed AST capacity in selected private hospitals in Western Uganda to identify gaps and support integration into Uganda’s national AMR response framework.

Methods

Study design, settings and sampling: We conducted a cross-sectional assessment during May-June 2025 in three purposively selected private hospitals with functional microbiology laboratories in western Uganda. B and A hospitals in Mbarara District and C hospital in Kabale District. These hospitals had provided medical and surgical services for more than five years and had patient volumes comparable to Uganda’s regional referral hospitals. The region was selected because of increasing antimicrobial resistance (AMR) trends reported(11).

Data collection: Data were collected using the US Centres for Disease Control and Prevention-validated Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) questionnaire administered in Microsoft Excel format during May–June, 2025. The LAARC tool is designed to assess laboratory readiness for reliable bacteriology and AMR testing in resource-limited settings. It consists of 15 modules: general, facility, laboratory information system, data management, quality assurance, media quality control, identification quality control, antimicrobial susceptibility testing (AST) quality control, specimen management, processing, identification methods and standard operating procedures, basic AST, AST expert rules, AST policy, and safety. Four laboratory personnel from each hospital, including the laboratory manager, quality officer, and bench personnel were interviewed to complete the LAARC-tool resulting in a total of 12 respondents. Laboratory processes and supporting documents, including standard operating procedures, were reviewed at each facility. Data collection was conducted by two clinical microbiology experts.

Data analysis: The LAARC tool uses a self-scoring approach in which indicators are scored from 0–100%. Scores were categorized as low capacity (0–49%), moderate capacity (50–79%), and good capacity (80–100%). Individual hospital scores were generated by averaging module scores, and overall AST capacity was calculated as the mean across facilities. Module-level analysis was used to identify the main factors affecting AMR testing performance.

Ethics consideration: This assessment was authorized by the Ministry of Health (MoH) and classified as a non-research public health activity. It was therefore exempted from full Institutional Review Board (IRB) review and conducted in accordance with applicable Centres for Disease Control and Prevention policies.

Results

This study enrolled three private hospital laboratories from two districts of western Uganda. All the three private hospital laboratories assessed had a physical laboratory infrastructure on site. However, none of the hospital laboratories had good capacity (80%) to conduct AMR testing.  The overall average score for AMR testing capacity was 53%, with B hospital scoring highest with 61% (moderate capacity) with A and C Hospitals scoring 49% (low capacity).

Seven out of thirteen assessed modules were the key areas that affected the AMR testing performance as their scores were below 50%. These included processing 48%, AST expert rules 46%, Quality control 43%, AST-panels, policy and analysis36%, Quality control-AST 34%, and identification methods and SOPs at 31% (Figure 1).

Discussion

This assessment using the Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool demonstrated moderate-to-low antimicrobial susceptibility testing (AST) capacity among private hospital laboratories in Western Uganda, with an overall average score of 53% and no facility achieving good capacity (≥80%). Hospital B demonstrated the highest overall performance. Across the assessed hospitals, the lowest-performing domains were identification methods, AST quality control, AST panels/policy/analysis, overall quality control, AST expert rules, and specimen processing, with performance ranging from 31% to 48%, indicating weaknesses that may compromise the accuracy and reliability of AST results and reduce their value for AMR surveillance.

These findings are consistent with evidence from Uganda and other sub-Saharan African settings showing persistent gaps in laboratory readiness for AMR testing, particularly in non-reference facilities(12). Uganda’s Mapping Antimicrobial Resistance and Antimicrobial Use Partnership (MAAP) assessment similarly demonstrated wide variation in laboratory readiness, with scores ranging from 36.8% to 81.6%, while facilities with characteristics comparable to those assessed in this study reported moderate performance levels(12). Routine surveillance data from Ugandan tertiary hospitals also show ongoing challenges associated with inconsistent AST practices and weak quality systems contributing to resistance trends (13). Similar barriers have been reported in private hospitals in Kampala, including limited antimicrobial stewardship implementation, inadequate training, and poor routine monitoring of susceptibility patterns (14, 15). Regional evidence further supports these findings. Studies from Zambia using the LAARC framework reported comparable deficiencies in AST quality control, pathogen identification, laboratory information systems, and specimen processing, highlighting shared constraints related to workforce capacity, reagent availability, infrastructure, and adherence to standard operating procedures (16-18). Collectively, these findings suggest that the challenges observed are systemic rather than facility-specific. Strengthening training in organism identification and quality control, improving access to standardized AST panels and expert rules, strengthening laboratory information systems and supply chains, and integrating private hospitals into national surveillance platforms are essential to support Uganda’s National Action Plan on AMR (NAP-AMR II) and reduce reliance on empirical antimicrobial prescribing.

Study limitations and strengths: This assessment had some limitations. First, only three purposively selected private hospitals with functional microbiology laboratories were included, limiting the representativeness and generalizability of the findings to other private hospitals and healthcare facilities in Uganda. Second, the cross-sectional design provided a snapshot of AST capacity during the assessment period and may not reflect changes in laboratory performance over time. Despite these limitations, the assessment provides valuable insights into key gaps in AST capacity within selected private hospitals and highlights priority areas for strengthening laboratory systems to support AMR surveillance.

Conclusion: Private hospital laboratories in Western Uganda demonstrated moderate-to-low AST capacity, with critical deficiencies in organism identification, quality control, expert rules, and specimen processing. These gaps limit reliable AMR surveillance and evidence-based antimicrobial use. Targeted investments in laboratory strengthening, standardized testing systems, workforce development, improved reagent availability, implementation of laboratory information systems, and integration into national AMR surveillance structures are necessary to strengthen diagnostic readiness and support AMR containment efforts in Uganda.

Conflict of interest: The authors declare that they have no conflict of interest.

Author contribution: NV took the lead in conceptualizing the project, data curation, investigation analysis writing the original draft. BS, BM, KM were involved investigation, designing methods, writing, reviewing the article. SG, MRE were involved in supervision and editing to ensure scientific integrity. All authors read and approved the final article.

Acknowledgments: The authors express sincere gratitude to the administration and staff of the participating hospitals from Mbarara and Kabale districts for their technical and administrative support offered during the investigation.

Copyright and licensing policy: All materials in the Uganda Public Health Bulletins is in the public domain and may be used and printed without permission. However, citation as to source is appreciated. Any article can be reprinted or published. If cited as a reprint, it should be referenced in the original form.

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