African Journal of Laboratory Medicine ISSN: (Online) 2225-2010, (Print) 2225-2002 Page 1 of 8 Review Article Surveillance of antimicrobial resistance in human health in Tanzania: 2016–2021 Authors: Background: Antimicrobial resistance (AMR) surveillance plays an important role in early Neema Camara1 2 detection of resistant strains of pathogens and informs treatments decisions at local, regional Nyambura Moremi Janneth Mghamba1 and national levels. In 2017, Tanzania developed a One Health AMR Surveillance Framework Eliudi Eliakimu3 to guide establishment of AMR surveillance systems in the human and animal sectors. Edwin Shumba4 Pascale Ondoa4 Aim: We reviewed AMR surveillance studies in Tanzania to document progress towards Beverly Egyir5 establishing an AMR surveillance system and determine effective strengthening strategies. Affiliations: Methods: We conducted a literature review on AMR studies conducted in Tanzania by 1Epidemiology and Disease searching Google Scholar, PubMed, and the websites of the Tanzania Ministry of Health and Control Section, Ministry of the World Health Organization for articles written in English and published from January Health, Dodoma, United Republic of Tanzania 2012 to March 2021 using relevant search terms. Additionally, we reviewed applicable guidelines, plans, and reports from the Tanzanian Ministry of Health. 2Department of Bacteriology, National Public Health Results: We reviewed 10 articles on AMR in Tanzania, where studies were conducted at Laboratory, Dar es Salaam, hospitals in seven of Tanzania’s 26 regions between 2012 and 2019. Nine AMR sentinel sites United Republic of Tanzania had been established, and there was suitable and clear coordination under ‘One Health’. However, sharing of surveillance data between sectors had yet to be strengthened. Most 3Health Quality Assurance studies documented high resistance rates of Gram-negative bacteria to third-generation Unit, Ministry of Health, Dodoma, United Republic of cephalosporins. There were few laboratory staff who were well trained on AMR. Tanzania Conclusion: Important progress has been made in establishing a useful, reliable AMR 4African Society for surveillance system. Challenges include a need to develop, implement and build investment Laboratory Medicine, Addis case studies for the sustainability of AMR surveillance in Tanzania and ensure proper use of Ababa, Ethiopia third-generation cephalosporins. 5Department of Bacteriology, What this study adds: This article adds to the knowledge base of AMR trends in Tanzania and Noguchi Memorial Institute progress made in the implementation of AMR surveillance in human health sector as a for Medical Research, College contribution to the global AMR initiatives to reduce AMR burden worldwide. It has highlighted of Health Sciences, University of Ghana, Legon, Ghana key gaps that need policy and implementation level attention. Keywords: surveillance; antimicrobial resistance; COVID-19; One Health; Tanzania; Africa. Corresponding author: Neema Camara, nemdorcam@yahoo.com Introduction Dates: Received: 08 Aug. 2022 Antimicrobial resistance (AMR) is a global public health threat with extensive social, health and Accepted: 09 Mar. 2023 economic impacts.1,2 Globally, it accounts for about 700 000 deaths annually.3 Antimicrobial Published: 22 May 2023 resistance threatens the lives of 10 million people and an economic loss of up to $100 trillion (United States dollar [USD]) per year by 2050, if there are no effective interventions.3 It is estimated that the magnitude of the AMR burden falls on low- and middle-income countries.3 Antimicrobials are the mainstay of modern medicine; without them, medical procedures, including surgeries, joint replacements, and treatments, such as cancer chemotherapy, could become too risky to be undertaken as healing would take a long time and become costly.3 In 2015, the World Health Assembly, through its 68th session, adopted the Global Action Plan on AMR to ensure the treatment and prevention of infectious diseases with quality-assured, safe, and effective medicines available.4 The Global Action Plan outlines five strategic objectives, which are: (1) to improve awareness and understanding of AMR; (2) to strengthen knowledge through surveillance and research; (3) to reduce the incidence of infection; (4) to optimise the use of Read online: antimicrobial agents; and (5) to ensure sustainable investment in countering AMR.4 To support Scan this QR code with your the implementation of the Global Action Plan, during the same year, the World Health smart phone or mobile device How to cite this article: Camara N, Moremi N, Mghamba J, et al. Surveillance of antimicrobial resistance in human health in Tanzania: to read online. 2016–2021. Afr J Lab Med. 2023;12(1), a2053. https://doi.org/10.4102/ajlm.v12i1.2053 Copyright: © 2023. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. http://www.ajlmonline.org Open Access Page 2 of 8 Review Article Organization (WHO) launched the Global AMR Surveillance census was 44 928 923.8 Tanzania Mainland has 26 System (GLASS), the first global collaborative effort to administrative regions, 139 districts and 184 councils. The standardise AMR surveillance.5 The GLASS provides a council divides into divisions, then wards, and streets/ standardised approach for collecting, analysing, and sharing villages. The local government authorities (or councils) are AMR data and documents the status of existing or newly the most important administrative and implementation units developed national AMR surveillance systems.5 for public services. In 2016, Tanzania developed the National Action Plan for Health services in Tanzania are decentralised into three AMR (2017–2022) following the WHO and Global Health categories: district (primary level), regional (secondary level), Security Agenda Joint External Evaluation recommendation. and zonal and national hospital (tertiary level). The district Subsequently, a holistic One Health AMR Surveillance level provides primary health care services through Framework was developed to guide the establishment of AMR dispensaries at the village level, health centres at the ward surveillance systems in the human, animal and environmental level, and Level 1 Hospital at the council level.9 Dispensaries health sectors. The country is bordered by more than eight provide preventive and curative out-patient services. In countries, which poses a high risk of pathogen importation contrast, health centres admit patients and sometimes into the country. In addition, several socioeconomic, provide surgical services. Council hospitals provide demographic and environmental factors also facilitate the healthcare to referred patients and provide medical and basic emergence and spread of microorganisms; thus, robust health surgical services. Regional Referral Hospitals provide systems are paramount for detecting, responding, and specialist medical care. Zonal and national hospitals offer mitigating the effects of the resistant microbes. advanced (super specialist) medical care and are teaching hospitals for medical, paramedical, and nursing training.9 In this current global coronavirus disease 2019 (COVID-19) Public, private and faith-based organisations health facilities, pandemic situation, where scientists are struggling to find an private pharmacies, and accredited drug dispensing outlets effective treatment for COVID-19, antibiotics have been provide pharmaceutical services.10,11 widely used to manage COVID-19, either to treat COVID-19 itself or co-infections.6 In fact, recent studies have shown the Results rampant use of antibiotics by most COVID-19 patients Antimicrobial resistance trends of priority without bacterial co-infections.7 pathogens in Tanzania This paper reviewed AMR surveillance studies and A total of 10 articles on AMR in Tanzania were retrieved and documents the progress made in establishing the AMR reviewed. These studies were conducted at either the zonal or surveillance system in the human health sector in Tanzania regional referral hospitals between 2012 and 2019. Four of the and provides recommendations for strengthening it. The 10 studies were conducted at Kilimanjaro Christian Medical literature review was essential to contextualise the AMR Centre in the Kilimanjaro region, three at Bugando situation in the past decade and the need to strengthen AMR Medical Centre in Mwanza region, two at Muhimbili National surveillance. Hospital in Dar es Salaam region, and one study each at Maweni Regional Referral Hospital in Kigoma region, Methods Musoma Regional Referral Hospital in Mara region, Sumbawanga Regional Referral Hospital in Rukwa region, Data collection St. Benedict Ndanda Hospital in Mtwara region, Bagamoyo We searched Google Scholar, PubMed, and websites of the District Hospital in Pwani region, Sekou Toure Regional Tanzania Ministry of Health and WHO written in English and Referral Hospital, Nyamagana District Hospital, and published from January 2012 to March 2021. We used the search Sengerema District Designated Hospital in Mwanza region terms: ‘antimicrobial resistance’, ‘bacterial resistance’, ‘antibiotic (Figure 1). Blood, pus and wound swabs, and urine were the resistance’; ‘AMR surveillance’, or ‘surveillance’ or ‘cross- most common laboratory samples analysed (Table 1). All section’ or ‘review’; and ‘Tanzania’. All words were searched of the studies performed antimicrobial susceptibility together, and, in some instances, two of the three words were testing (AST) using the disk-diffusion method per the 12 used. We reviewed guidelines, plans, and reports from the Clinical Laboratory Standards Institute guidelines. The most frequently isolated microorganisms from blood were Ministry of Health to describe the Tanzania AMR surveillance Staphylococcus aureus, Klebsiella pneumoniae and Escherichia system’s objective, surveillance sites, data collection, reporting, coli; and from pus, Pseudomonas aeruginosa (Table 1). S. aureus analysis, interpretation, and dissemination, coordination of resistance to clindamycin ranged between 33.3% to 68.4% and AMR surveillance activities, and funding of AMR surveillance. erythromycin between 35.6% to 76.3%, while resistance to cotrimoxazole was 82.6% and ampicillin was 100%.13,14,15,16 The Setting and structure of healthcare system in studies reported low rates of resistance to cefoxitin (27.3%), Tanzania tetracycline (34.9%), cotrimoxazole (26.5%) and ceftriaxone The United Republic of Tanzania comprises Tanzania’s (11.1%).14,17,18 Prevalence of methicillin-resistant S. aureus Mainland and the semiautonomous Islands of Zanzibar, and decreased from 41.2% in 2013 to 9.5% in 2015, but rose it lies on the East African coast. The Tanzania 2012 population to 66.7% in 2018.14,15 K. pneumoniae was resistant to http://www.ajlmonline.org Open Access Page 3 of 8 Review Article 0 100 200 Kilometres AMR, antimicrobial resistance. FIGURE 1: Antimicrobial resistance study locations and sentinel surveillance sites, August 2021, Tanzania. ampicillin (100%), cotrimoxazole (96.3%), ceftriaxone (95.7%), burden of the WHO priority pathogens, and monitor AMR amoxicillin/clavulanate (94.6%), ceftazidime (90.9%), interventions’ effectiveness. The country also established a gentamycin (86.4%) and cefepime (75.6%).13,16,19 Compared to national Multi-Sectoral Coordinating Committee (MCC) to other Gram-negatives, E. coli was more resistant to ampicillin, oversee and coordinate all AMR-related activities in all sectors. amoxicillin-clavulanic acid, gentamycin, tetracycline, The Chief Medical Officer of the Ministry of Health and the ciprofloxacin, amikacin, third-generation cephalosporins Director of Veterinary Services, Ministry of Livestock and (ceftazidime and ceftriaxone) and cefepime.,13,15,16,19,20 Notably, Fisheries alternate as co-chair of the committee. The committee P. aeruginosa was resistant to cefepime (93.8%).13 Overall, is composed of representatives from the human, animal and most studies documented high resistance rates of Gram- environmental health sectors, as well as livestock and food negative bacteria to third-generation cephalosporins.17,21,22 production stakeholders, and those from medical and Progress in implementation of antimicrobial agricultural universities. The WHO, Food and Agriculture resistance surveillance Organization, United States Centres for Disease Control and Prevention, Management Science for Health and World Coordination Organization for Animal Health, are also represented in the In 2018, Tanzania took the first step of developing a One MCC. There are designated national AMR focal points from Health National AMR surveillance framework to guide animal and human sectors that form part of the MCC secretariat, the establishment of AMR surveillance programmes in the as well as four multisectoral Technical Working Groups on (1) country. The framework provides a holistic approach to awareness, effective communication and education; (2) monitor trends of infections and resistance that will inform knowledge, surveillance, research and sustainable investments; standard treatment guidelines that support best practices for (3) sanitation, hygiene and infection prevention and control; patient care, and links AMR information from the human, and (4) antimicrobial use stewardship. The MCC and animal and environmental health sectors.23 The objectives of surveillance TWG meets at least once every quarter of the year. AMR surveillance are to routinely collect, analyse, and interpret The whole coordination structure operates under the ‘One quality AMR data to generate evidence on trends and the Health’ and whole-of-government approach. http://www.ajlmonline.org Open Access Page 4 of 8 Review Article TABLE 1: Antimicrobial resistance trends of GLASS priority pathogens in Tanzania, 2012–2021. S/N Title of the study, Ref Year of study Sources of isolates Study Organisms Antimicrobial resistance rates (%) Study type population recovered most 1 Causative agents and February to Wound swabs Out-patient Staphylococcus Penicillin (96.2), tetracyclines Hospital- antimicrobial resistance October aureus (34.9), cotrimoxazole (26.5), based patterns of human skin and 2012 Erythromycin (35.6) and soft tissue infections in clindamycin (33.3) Bagamoyo, Tanzania.14 2 Antimicrobial resistance June 2013 to Blood Children and Staphylococcus Methicillin (34.6) MRSA < from Hospital- pattern: A report of May 2015 adults aureus 41.2% in 2013 to 9.5% in 2015 based microbiological cultures at a tertiary hospital in Klebsiella 3rd-generation cephalosporin Tanzania.21 pneumoniae (38.5) Salmonella spp. 3rd-generation cephalosporin (39.0) Urine Escherichia coli 3rd-generation cephalosporin (29.3) Pus swab Gram-negative 3rd-generation cephalosporin > bacteria from 26.5 in 2014 to 57.9 in 2015 3 Patterns of infections, August 2013 Stool, sputum, blood, In-patients Gram-negative Cefazolin (72.9), ceftriaxone (51.8), Hospital- aetiological agents and to August wound/pus swab from surgical bacteria (Proteus ceftazidime (37.4) based antimicrobial resistance at 2015 and medical spp., Escherichia a tertiary care hospital in wards coli, Klebsiella spp. northern Tanzania.17 and Pseudomonas spp.) Staphylococcus Cefoxitin (27.3), Penicillin (100) aureus 4 Prevalence and April 2016 to Urine and stool All patients Escherichia coli Cephalosporin (70.0), amikacin Hospital- antimicrobial resistance May 2016 (60.0) based patterns of extended spectrum beta-lactamase producing E. Coli in human isolates at Kilimanjaro Medical Centre, Moshi, Tanzania.20 5 Deciphering risk factors for July 2016 to Blood < 5 years of Klebsiella Ampicillin (100.0), trimethoprim- Hospital- blood stream infections, October age pneumoniae sulfamethoxazole (SXT) (96.3), AMC based bacteria species and 2017 Amoxycillin-clavulanate (94.6), CAZ antimicrobial resistance Ceftazidime (90.9), CRO Ceftriaxone profiles among children (95.7) under five years of age in North-Western Tanzania: A Staphylococcus Ampicillin (100.0), SXT multicentre study in a aureus trimethoprim-sulfamethoxazole cascade of referral health (82.6), ERY Erythromycin (65.2) care system.16 Escherichia coli Ampicillin (100.0), SXT trimethoprim-sulfamethoxazole (94.4), ciprofloxacin (52.9), AMC Amoxycillin-clavulanate (94.1), CRO (58.8), CAZ (52.9) 6 Laboratory confirmed December Blood and Women Escherichia coli Ceftriaxone (64.7), ampicillin (67.6) Hospital- puerperal sepsis in a 2017 to April endocervical swabs suspected of and ceftazidime (63.2) based national referral hospital in 2018 puerperal Tanzania: Etiological agents sepsis Klebsiella spp. Ceftriaxone (77.3), gentamicin and their susceptibility to (86.4), ampicillin (81.8), ceftazidime commonly prescribed (86.4) antibiotics.19 Staphylococcus Methicillin (53.8) aureus 7 Antibiotic resistance in September Pus swab Diabetic foot Escherichia coli Ceftriaxone (50.0), Amoxicillin and Hospital- aerobic bacterial isolates 2018 to ulcers clavulanic acid (47.6) based from infected diabetic foot March 2019 admitted at ulcers in North Eastern the surgical Pseudomonas Amikacin (42.9) Tanzania: An urgent call to department aeruginosa establish a hospital antimicrobial stewardship committee.22 8 Antibiotic susceptibility October Ear pus, urine, wound In-patient and Staphylococcus Erythromycin (76.3), Gentamycin Hospital- patterns of bacterial 2018 to pus, stool and blood out-patient aureus (54.0), Ciprofloxacin (40.0) and based isolates from routine September Clindamycin (34.9). MRSA (66.7) clinical specimens from 2019 referral hospitals in Escherichia coli Ampicillin (100.0), Amoxicillin- Tanzania: A prospective Clavulanic Acid (75.0), Gentamicin hospital-based (70.2), Tetracycline (70.2) and observational study.15 Ciprofloxacin (42.6) 9 Etiologies of bloodstream April 2019 to Blood Out-patient Staphylococcus 1 out of 3 isolates was resistant to Hospital- infection and antimicrobial June 2019 and in-patient aureus Meropenem, Cefotaxime, Amikacin, based resistance: A cross Gentamicin, Imipenem, and sectional study among ceftriaxone (11.1) patients in a tertiary hospital, Northern Tanzania.18 10 The existence of high July 2019 to Blood, urine, pus, Out-patient and Staphylococcus Clindamycin (68.4) Hospital- bacterial resistance to some November 2019 in-patient aureus based reserved antibiotics in tertiary hospitals in Tanzania: Pseudomonas Cefepime (93.8) A call to revisit their use.13 aeruginosa Klebsiella spp. Cefepime (75.6) Escherichia coli Cefepime (56.3) Klebsiella spp. Ceftriaxone (77.3), gentamicin (86.4), ampicillin (81.8), ceftazidime (86.4) MRSA, methicillin-resistant Staphylococcus aureus; S/N, serial number; Ref, reference. http://www.ajlmonline.org Open Access Page 5 of 8 Review Article Antimicrobial resistance surveillance system Clinical data and AST positive culture results are recorded in Tanzania started with laboratory-based AMR surveillance the reporting forms and entered into the laboratory in healthcare settings, as laboratory-based surveillance is information system and the World Health Organization the most efficient AMR burden determination method.24,25 In Network (WHONET), a freely available system for capturing, the first phase of the national Tanzania AMR surveillance analysing and sharing AMR data in a standardised format. there were two laboratory levels: coordinating laboratory Data import into WHONET can be semi-automated using and site (sentinel/participating) laboratories. As of 2022, the add-on Baclink software (WHO Collaborating Centre there are a total of nine AMR sentinel sites which are active for Surveillance of Antimicrobial Resistance, Boston, and functional. The sentinel sites include Muhimbili Massachusetts, United States), which allows for import from National Hospital, Mbeya Zonal Referral Hospital, Bugando other data sources, for example, text files exported from a Medical Centre, Kilimanjaro Christian Medical Centre, laboratory information management system (LIMS) or Mnazi Mmoja Hospital in Zanzibar, Temeke Regional directly from a laboratory instrument.27 However, WHONET Referral Hospital in Dar es Salaam region, Morogoro intentionally provides only a solution for basic laboratory Regional Referral Hospital in Morogoro region, Maweni specimen management and result reporting and does Regional Referral Hospital in Kigoma region, and Benjamin not have comprehensive LIMS functionality.27 Laboratory Mkapa Hospital in Dodoma region (Figure 1). The National departments communicate AST results immediately to Health Laboratory (NHL) is the national coordinating clinicians as well as the infection prevention and control and laboratory, and its primary roles include: developing AMR AMR teams for appropriate treatment and control programs national standard operating procedures; training, mentoring in the local setting. Target pathogens for monitoring and and supervising sentinel laboratories; conducting external reporting as per the national and WHO priorities include quality assurance and monitoring internal quality assurances E. coli, K. pneumoniae, Acinetobacter baumannii, S. aureus, done by sentinel laboratories; and compiling, aggregating, Neisseria meningitidis, Streptococcus pneumoniae, Salmonella analysing, visualising and disseminating national AMR spp., Shigella spp., Pseudomonas spp. and Neisseria gonorrhoeae. surveillance data to the national MCC and the GLASS. On the other hand, sentinel laboratories isolate and identify Data analysis, interpretation and dissemination organisms; perform susceptibility tests; store isolates as per The participating laboratories must clean, collate, analyse, and national standardised operating procedures; produce and create site-specific bacterial antibiograms every month. In share timely antibiograms with clinicians; and conduct addition, annual AMR surveillance reports are shared with internal quality assurances. Antimicrobial resistance the relevant clinical departments and hospital committees to surveillance involves the routine collection of blood and increase hospital and community AMR awareness, inform urine specimens from in and out-patients with clinical signs treatment policies at the health facility, and encourage and symptoms attending the hospitals. Clinicians decide continued participation in the surveillance system. whether to take samples for microbiological culture based on the patient’s clinical assessment. Presently, the Antimicrobial resistance data from surveillance sites are participating laboratories employ phenotypic methods for centrally stored and managed at the NHL. The NHL conducts pathogen identification and disk diffusion for AST. The AST data quality checks, analysis, and visualisation, generates is a laboratory procedure to identify effective antimicrobial official AMR reports, and provides long-term data storage. agents that kill or prevent the growth of isolated Antimicrobial resistance surveillance reports, including pathogens recovered from samples of individual patients.26 trends and resistant pathogen prevalences, are generated at Antimicrobial susceptibility testing results guide clinicians least twice a year and disseminated to stakeholders after and service providers to decide on target therapy, approval by the AMR Surveillance Technical Working Group preserve drugs, and evaluate treatment services.26 Notably, and the national MCC. At the same time, the clean AMR data continuous surveillance for resistance patterns is crucial due set is transmitted to the GLASS (Figure 2). The AMR to the mutations in bacterial DNA.26 The AST is performed surveillance data guides strategies and policies for combating and interpreted according to international guidelines such AMR. It also provides opportunities for in-depth scientific as the Clinical and Laboratory Standards Institute guidelines. research that generates additional knowledge on AMR. The AST results are categorised into either susceptible (S) or However, sharing of surveillance data among sectors is yet to non-susceptible, which include intermediate (I) and resistant be strengthened, that is, environment, health and animal. (R) according to clinical breakpoints defined by Clinical and Tanzania started reporting AMR data to GLASS in June 2021. Laboratory Standards Institute. Patient clinical data, including infection origin (community or hospital), age, Quality assurance and standards gender and admission types (out-patient, in-patient, general All nine sentinel sites participate in the external quality ward or intensive care unit) are collected regardless of assurance which is being supported by NHL and African culture positivity or negativity. Infection origin are Society for Laboratory Medicine under the project called categorised as hospital-acquired (specimen from an in- External Quality Assessment for Africa. External quality patient admitted for > 2 days) or community-acquired assurance is done twice a year for all sites and involves most (specimen from an out-patient or in-patient admitted for of the GLASS priority pathogens, including E. coli, ≤ 2 days).23 K. pneumoniae, A. baumannii, S. aureus, N. meningitidis, http://www.ajlmonline.org Open Access Page 6 of 8 Review Article Paent specimen/sample - Culture Parcipang - Organism idenficaonClinical site hospital laboratory - Anmicrobial suscepbility tesng - Paents results - Anbiograms - Local anbioc treatment guideline Paent with suspected infecon - Compilaon of data Naonal Surveillance Naonal coordinang - Clean, collate and analyse MCC TWG laboratory - Report - External quality assurance Naonal AMR situaon report Public Global AMR situaon report WHO - GLASS AMR, antimicrobial resistance; TWG, Technical Working Group; MCC, Multi-Sectoral Coordinating Committee; WHO, World Health Organization; GLASS, Global AMR Surveillance System; WHONET, World Health Organization Network FIGURE 2: Antimicrobial resistance data flow in Tanzania (9 January 2022). S. pneumoniae and Salmonella spp. As per the AMR surveillance Studies in Tanzania reveal increasing bacterial resistance to framework, all isolates are to be stored at −70 °C for future third-generation cephalosporins. In Tanzania, ceftriaxone is studies. Isolates with unusual, unexpected, or indeterminate reportedly prescribed excessively and inappropriately in resistance patterns are sent to the NHL for confirmatory hospital settings,28 and this may explain the observed third- testing and AST. Also, every 10th isolate from each site is generation cephalosporins resistance trends. If this trend sent to NHL for quality assessment. continues, clinicians will resort to broad-spectrum antibiotics, such as carbapenem, which are the last resort according to the Tanzania treatment guideline.29,30Funding If such a situation occurs, effective, quality, and affordable healthcare provisions, the Funds to run the nine AMR surveillance sentinel laboratories core fundamentals for universal health coverage, will be far are contributed by the Government of the United Republic of from being realised. Tanzania, the Fleming Fund, and the United States Agency for International Development fund under the Infectious Progress made in establishing the AMR surveillance system Disease Diagnostic and Surveillance project. Therefore, there in the country is commendable. A total of nine sentinel sites is a need to establish a sustainable funding mechanism for have been established. There are suitable coordination AMR activities in Tanzania. structures and platforms for multisectoral engagement and collaboration under the ‘One Health’.31 The AMR sentinel Discussion surveillance sites are representative and provide AMR trends and burden data. AMR surveillance system has This review has shown that the most frequently isolated helped to standardise routine microbiological cultures and microorganisms from blood were S. aureus, K. pneumoniae and AST in hospitals, particularly those participating in AMR E. coli; from urine, E. coli; and from pus, P. aeruginosa. Most surveillance according to global standards (MCC meeting studies documented high resistance rates of Gram-negative minutes of 11 May 2021, unpublished). However, the facilities bacteria to third-generation cephalosporins. Importantly, still face challenges while implementing AMR surveillance, significant progress has been made in establishing AMR including a lack of interoperability between the sentinel site surveillance; nine sentinel sites across Tanzania have been laboratory information system and WHONET to enable established and are generating data and there are suitable and automatic data transfer between the two systems. The double clear coordination structures and platforms for multisectoral entry of the same information in two different systems engagement and collaboration under One Health. However, exhausts and overworks the laboratory staff. A lack of fit-for- sharing of surveillance data between sectors is yet to be purpose LIMS and open-source LIMS software with technical strengthened. There are also few laboratory staff well trained standards and functionality for AMR surveillance is a on AMR practices. particular concern in low- and middle-income countries.27 http://www.ajlmonline.org Open Access - Naonal AMR situaon report - Naonal anbioc treatment guideline - Results reported via WHONET Naonal consolidated - 10th Isolate for confirmaon AMR data Disseminaon of AMR report Page 7 of 8 Review Article Although WHONET is a functional and useful repository for financing for laboratory infrastructure development and microbiological data with capabilities for standardised data continuous supply of reagents, commodities, and laboratory sharing, it lacks full LIMS functionality.27 Thus, there is an materials; and invests hugely in building human capacities urgent need for investment in laboratory information for bacterial identification and AST and data analysis, technology infrastructure and data management systems that interpretation and utilisation. can capture high-quality laboratory and patient management data. Acknowledgements There are few well-trained laboratory staff at the sentinel The authors would like to acknowledge the Government of sites for data analysis and the production of antibiograms, Tanzania and partners for the efforts to implement AMR which can be shared with the clinicians and AMR teams to surveillance activities. Also, we appreciate authors of the inform on the appropriate treatment and measures to tackle surveillance articles and contributors of the AMR reports, AMR at the hospital or community. At the surveillance sites, minutes, guidelines, and frameworks which informed this frequent stock out of AST reagents and analysis, inadequate writing. resources, and poor laboratory infrastructure for phenotypic and genotypic analysis is commonplace. Although AMR Competing interests surveillance receives much support from the government as per human resources and infrastructure, there are also funds The authors declare that they have no financial or personal from donors. A sustainability plan is essential to prevent relationships that may have inappropriately influenced them over-dependence on donors over time. These challenges are in writing this article. unique in Tanzania and have also been reported elsewhere in Africa.32,33 However, despite the challenges, AMR surveillance Authors’ contributions is still ongoing in the country. N.C., E.S., P.O. and B.E. were involved in the conceptualization of the project. N.C. and B.E, were involved in the writing of Sharing of surveillance data between sectors is yet to be an initial draft, reviewing and editing the manuscript. N.C., strengthened. Antimicrobial resistance is a broad and N.M., J.M, E.E., E.S., P.O., B.E. reviewed and edited the complex issue affecting the animal, human and environmental manuscript. All authors read and approved the final version sectors; thus, a multisectoral and multidisciplinary combat of the manuscript. approach is needed. Antimicrobials are also widely used in animals for treatment and growth promoters. In addition, evidence suggests that antimicrobial use in animals Ethical considerations contributes significantly to the development of AMR in This paper has no ethical concerns as it does not have human humans,34 necessitating a comprehensive and coordinated or animal subjects or data, and as such ethical approval from AMR surveillance system that can continuously share AMR an ethics review board was not required. data between sectors to inform public health interventions. This study has some limitations. The review was based on Sources of support reports only. We did not seek additional inputs and insights This work was part of the activities of a Fellowship (Surveillance from AMR stakeholders through a standardised questionnaire in Human Health) workplan, which was supported by the or interview. As such some comprehensive views and Fleming Fund through the Fellowship Scheme in Tanzania. perspectives may have been missed out. The AMR trends in Tanzania presented here should be interpreted with caution as Data availability the review was only based on 10 surveillance articles. The authors confirm that the data supporting the findings of this study are available within the article. Conclusion Tanzania is currently implementing AMR surveillance in Disclaimer nine hospitals, and reporting of AMR data to GLASS has commenced. There are well-established AMR coordination The views and opinions expressed in this article are those of mechanisms at health facilities and national levels to the authors and do not necessarily reflect the official policy or effectively implement and utilise the AMR information. position of any affiliated agency of the authors. Although there are challenges affecting implementation, the current AMR surveillance system in place is useful, reliable References and capable of better performance. There is a need to develop, 1. World Health Organization, editor. Antimicrobial resistance: Global report on implement and build an investment case study for the surveillance. World Health Organization; Geneva, 2014. sustainability of AMR surveillance in Tanzania. We 2. Howell L, World Economic Forum, risk response network. Global Risks 2013. World Economic Forum; Geneva, 2013. recommend that the government creates a fit-to-purpose 3. O’Neill J. Tackling drug-resistant infections globally: Final report and laboratory information system with functionality able to link recommendations: The review on antimicrobial resistance. World Bank; 2016 (cited 2020 April 10). Available from: https://amr-review.org/sites/default/ with other systems; develops a mechanism for sustainable files/160525_Final%20paper_with%20cover.pdf http://www.ajlmonline.org Open Access Page 8 of 8 Review Article 4. World Health Organization. 2015. Global action plan on antimicrobial resistance 19. Kiponza R, Balandya B, Majigo MV, Matee M. Laboratory confirmed puerperal [homepage on the Internet]. World Health Organization. c2015 (cited 2020 sepsis in a national referral hospital in Tanzania: Etiological agents and their September 13). Available from: https://apps.who.int/iris/handle/10665/193736 susceptibility to commonly prescribed antibiotics. BMC Infect Dis. 2019;19(1):690. 5. World Health Organization. Global Antimicrobial Resistance Surveillance System https://doi.org/10.1186/s12879-019-4324-5 (GLASS) report: Early implementation 2016–2017. World Health Organization; 20. Pratap FN. Prevalence and antimicrobial resistance patterns of extended spectrum Geneva, 2017. beta-lactamase producing E. Coli in human isolates at Kilimanjaro Medical Centre, 6. Iwu CJ, Jordan P, Jaja IF, Iwu CD, Wiysonge CS. Treatment of COVID-19: implications Moshi, Tanzania [homepage on the Internet]. Thesis. 2019 [cited 2021 Jun 15]. for antimicrobial resistance in Africa. Pan Afr Med J. 2020;35(Suppl 2):119. Available from: http://repository.costech.or.tz//handle/123456789/15023 https://doi.org/10.11604/pamj.supp.2020.35.2.23713 21. Moremi N, Claus H, Mshana SE. Antimicrobial resistance pattern: A report of 7. Rawson TM, Moore LSP, Zhu N, et al. Bacterial and fungal co-infection in microbiological cultures at a tertiary hospital in Tanzania. BMC Infect Dis. individuals with coronavirus: A rapid review to support COVID-19 antimicrobial 2016;16(1):756. https://doi.org/10.1186/s12879-016-2082-1 prescribing. Clin Infect Dis. 2020;71(9):2459–2468. https://doi.org/10.1093/cid/ ciaa530 22. Shabhay AA, Horumpende P, Mujuni M, et al. Antibiotic resistance in aerobic bacterial isolates from infected diabetic foot ulcers in North Eastern Tanzania: An 8. United Republic of Tanzania. Population and housing census 2012: Population urgent call to establish a hospital antimicrobial stewardship committee. Preprint distribution by administrative areas. Dar es Salaam: National Bureau of Statistics; 2021 Jun 8 [cited 2021 Jun 15]. https://doi.org/10.21203/rs.3.rs-569062/v1 2013. 23. United Republic of Tanzania. National Antimicrobial Resistance Framework. Dar es 9. Hokororo J, Eliakimu E, Ngowi R, et al. Report of Trend for Compliance of Infection Salaam: United Republic of Tanzania; 2018. Prevention and Control Standards in Tanzania from 2010 to 2017 in Tanzania Mainland. Microbiol Infect Dis. 2021; 5(3):1–10. 24. Mendelson M, Matsoso MP. The World Health Organization Global Action Plan for antimicrobial resistance. S Afr Med J. 2015;105(5):325–325. https://doi. 10. Minzi OM, Manyilizu VS. Application of basic pharmacology and dispensing org/10.7196/SAMJ.9644 practice of antibiotics in accredited drug-dispensing outlets in Tanzania. Drug Healthc Patient Saf. 2013;5:5–11. https://doi.org/10.2147/DHPS. 25. Perovic O, Schultsz C. Stepwise approach for implementation of antimicrobial S36409 resistance surveillance in Africa. Afr J Lab Med. 2016;5(3):7. https://doi.org/10.4102/ajlm.v5i3.482 11. Poyongo BP, Sangeda RZ. Pharmacists’ knowledge, attitude and practice regarding the dispensing of antibiotics without prescription in Tanzania: An explorative 26. Bayot ML, Bragg BN. Antimicrobial susceptibility testing [homepage on the cross-sectional study. Pharmacy. 2020;8(4):238. https://doi.org/10.3390/ Internet]. StatPearls Publishing; 2021 [cited 2021 Mar 07]. Available from: http:// pharmacy8040238 www.ncbi.nlm.nih.gov/books/NBK539714/ 12. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for 27. Turner P, Rupali P, Opintan JA, et al. Laboratory informatics capacity for effective Antimicrobial Susceptibility Testing. 27th ed. CLSI supplement M100. Pennsylvania: antimicrobial resistance surveillance in resource-limited settings. Lancet Infect Clinical and Laboratory Standards Institute; 2017. Dis. 2021;21(6):e170–e174. https://doi.org/ 10.1016/S1473-3099(20)30835-5 13. Mikomangwa WP, Bwire GM, Kilonzi M, et al. The existence of high bacterial 28. Sonda TB, Horumpende PG, Kumburu HH, et al. Ceftriaxone use in a tertiary care resistance to some reserved antibiotics in tertiary hospitals in Tanzania: A call to hospital in Kilimanjaro, Tanzania: A need for a hospital antibiotic stewardship revisit their use. Infect Drug Resist. 2020;13:1831–1838. https://doi.org/10.2147/ programme. PLoS One. 2019;14(8):e0220261. https://doi.org/ 10.1371/journal. IDR.S250158 pone.0220261 14. Kazimoto T, Abdulla S, Bategereza L, et al. Causative agents and antimicrobial 29. Mushi MF, Mshana SE, Imirzalioglu C, Bwanga F. Carbapenemase genes among resistance patterns of human skin and soft tissue infections in Bagamoyo, multidrug resistant gram-negative clinical isolates from a tertiary hospital in Tanzania. Acta Trop. 2018;186:102–106. https://doi.org/ 10.1016/j.actatropica. Mwanza, Tanzania. BioMed Res Int. 2014;2014:e303104. https://doi. 2018.07.007 org/10.1155/2014/303104 15. Mnyambwa NP, Mahende C, Wilfred A, et al. Antibiotic susceptibility patterns of 30. Ssekatawa K, Byarugaba DK, Wampande E, Ejobi F. A systematic review: The bacterial isolates from routine clinical specimens from referral hospitals in current status of carbapenem resistance in East Africa. BMC Res Notes. Tanzania: A prospective hospital-based observational study. Infect Drug Resist. 2018;11(1):629. https://doi.org/10.1186/s13104-018-3738-2 2021;14:869–878. https://doi.org/10.2147/IDR.S294575 31. Frumence G, Mboera LEG, Sindato C, et al. The governance and implementation 16. Seni J, Mwakyoma AA, Mashuda F, et al. Deciphering risk factors for blood stream of the national action plan on antimicrobial resistance in Tanzania: A infections, bacteria species and antimicrobial resistance profiles among children qualitative study. Antibiotics. 2021;10(3):273. https://doi.org/10.3390/ under five years of age in North-Western Tanzania: A multicentre study in a antibiotics 10030273 cascade of referral health care system. BMC Pediatr. 2019;19(1):32. https://doi. 32. Kariuki S, Keddy KH, Antonio M, Okeke IN. Antimicrobial resistance surveillance in org/10.1186/s12887-019-1411-0 Africa: Successes, gaps and a roadmap for the future. Afr J Lab Med. 2018;7(2):924. 17. Kumburu HH, Sonda T, Mmbaga BT, et al. Patterns of infections, aetiological agents https://doi.org/10.4102/ajlm.v7i2.924 and antimicrobial resistance at a tertiary care hospital in northern Tanzania. Trop 33. Ndihokubwayo JB, Yahaya AA, Desta AT, et al. Antimicrobial resistance in the Med Int Health. 2017;22(4):454–464. https://doi.org/10.1111/tmi.12836 African Region: Issues, challenges and actions proposed. African Health Monitor. 18. Mauki II, William JD, Mlay HL, et al. Etiologies of bloodstream infection and 2023;(16):4. antimicrobial resistance: A cross sectional study among patients in a tertiary 34. Carrique-Mas JJ, Choisy M, Van Cuong N, Thwaites G, Baker S. An estimation of hospital, Northern Tanzania. East Afr Sci. 2021;3(1):104–111. https://doi. total antimicrobial usage in humans and animals in Vietnam. Antimicrob Resist org/10.24248/EASci-D-20-00012 Infect Control. 2020;9(1):16. https://doi.org/10.1186/s13756-019-0671-7 http://www.ajlmonline.org Open Access