Implementing AMR surveillance at a tertiary hospital in a low-income country: results from the Surveillance Partnership to Improve Data for Action on AMR (SPIDAAR) in Malawi

Antimicrobial resistance (AMR) is a growing global health threat, particularly in low- and middle-income countries (LMICs) where infectious diseases are more prevalent. Effective surveillance in these settings is key for tracking resistance trends and informing public health interventions, yet few implementation studies have delineated the particular challenges and opportunities for antimicrobial stewardship (AMS) activities in LMICs. The objective of this study was to evaluate the impact of a multi-component AMR surveillance capacity-building intervention on institutional surveillance capacity, healthcare worker knowledge and practices, and antimicrobial prescribing patterns at a tertiary referral hospital in Malawi. The study was conducted at Queen Elizabeth Central Hospital (QECH), a large tertiary hospital in southern Malawi. QECH was one of four sites participating in the Surveillance Partnership to Improve Data for Action on AMR (SPIDAAR), a multi-component capacity-building initiative supported by Pfizer Inc. and the Wellcome Trust, implemented over a 3-year period. The impact of this intervention on AMS practices and AMR surveillance capacity at this site was evaluated using a quasi-experimental approach including healthcare worker assessments and patient file reviews. A total of 263 and 248 healthcare workers were surveyed at baseline and intervention end period, respectively. 100 patient file reviews were conducted in parallel with the surveys at baseline and end of intervention. There were demonstrable improvements in AMR surveillance across the multiple domains of interest, including clinical assessment, microbiology processes, and data management. Knowledge of the national AMR action plan (NAP) improved from 13.6% to 45.6%, and laboratory request form completeness increased from 48.6% to 73.9%. Empirical antimicrobial prescribing at admission did not change significantly. The persistent gap between self-reported and observed clinical practices highlighted an enduring knowledge-practice challenge. A structured, multi-component AMR surveillance intervention can achieve meaningful improvements in surveillance capacity and healthcare worker knowledge in a tertiary hospital in a low-income country setting. Progress was facilitated by national policy alignment and hospital leadership engagement, and constrained by the absence of integrated electronic data systems and a persistent gap between AMS knowledge and clinical practice. These findings have relevance for similar LMIC settings seeking to strengthen AMR surveillance capacity.