IJID regions · 2026
Small-sample antimicrobial resistance surveillance using lot quality assurance sampling in Uganda, Malawi, and Zambia.
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Anguyo Robert Onzima, Uadiale Kennedy, Chilembo Phillip, Chilekwa Joyce Chinyama, Ekirapa-Kiracho Elizabeth, Feasey Nicholas, Ictho Jerry, Lamadrid Angelo, Kitutu Freddy Eric, Kajumbula Henry, Kazimbaya Katayi, Lochoro Peter, Mayora Chrispus, Mukisa Pius, Nkolo Charles Lubanga, O'Byrne Thomasena, Pagano Marcello, Mwape Kapambwe, Simuyandi Michelo, Betts Hannah, Roberts Adam P, Sharma Anjali, Valadez Joseph J
Аннотация
OBJECTIVES: We evaluated lot quality assurance sampling (LQAS) adapted for antimicrobial resistance (AMR) surveillance (AMR-LQAS), a small-sample approach designed to classify district AMR prevalence against a clinically meaningful resistance threshold in Uganda, Malawi, and Zambia.
METHODS: The study was conducted across nine districts/locations, with each country including one urban, one peri-urban, and one rural district/location. Upper and lower resistance thresholds were 20% and 5%, respectively, with predefined misclassification probabilities (α = 0.05, β = 0.10), yielding a minimum sample size of 44 per district. In Uganda, classifications were compared with larger probability samples (n ≥ 240 in each of three districts). Organisms assessed included extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus. Antibiotics assessed were those routinely used in the study countries.
RESULTS: In Uganda, concordance between AMR-LQAS and probability-sample classifications was nine of 12 organism-district comparisons. Across antibiotic-district comparisons, concordance was 46/48, resulting in overall reliability of 92% (55/60 comparisons). Resistance to ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole in ESBL-producing E. coli exceeded the 20% threshold in all districts, whereas meropenem resistance exceeded the threshold in only one district. Zambia had fewer antibiotics below resistance thresholds than Uganda and Malawi.
CONCLUSION: AMR-LQAS reliably classified district-level resistance using substantially smaller sample sizes than conventional prevalence surveys, generating actionable subnational information to support antibiotic stewardship and surveillance in low-resource settings.
METHODS: The study was conducted across nine districts/locations, with each country including one urban, one peri-urban, and one rural district/location. Upper and lower resistance thresholds were 20% and 5%, respectively, with predefined misclassification probabilities (α = 0.05, β = 0.10), yielding a minimum sample size of 44 per district. In Uganda, classifications were compared with larger probability samples (n ≥ 240 in each of three districts). Organisms assessed included extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus. Antibiotics assessed were those routinely used in the study countries.
RESULTS: In Uganda, concordance between AMR-LQAS and probability-sample classifications was nine of 12 organism-district comparisons. Across antibiotic-district comparisons, concordance was 46/48, resulting in overall reliability of 92% (55/60 comparisons). Resistance to ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole in ESBL-producing E. coli exceeded the 20% threshold in all districts, whereas meropenem resistance exceeded the threshold in only one district. Zambia had fewer antibiotics below resistance thresholds than Uganda and Malawi.
CONCLUSION: AMR-LQAS reliably classified district-level resistance using substantially smaller sample sizes than conventional prevalence surveys, generating actionable subnational information to support antibiotic stewardship and surveillance in low-resource settings.