Epidemiology of Bloodstream Bacterial Infections and Missed Opportunities to Detect and Respond to Possible Outbreaks Due to Drug-Resistant Bacteria in Hospitals in Uganda: A Review of Retrospective National AMR Surveillance Data 2020 to 2023

<ns3:p> Background Antimicrobial resistance (AMR) poses a critical global health threat, with low- and middle-income countries (LMICs) facing systemic challenges in the detection and response to outbreaks of resistant pathogens. Despite Uganda establishing a national AMR surveillance system, there are no systems for the real-time detection of AMR outbreaks due to limited laboratory capacity, standardised protocols and data management systems. Methods This study involved a retrospective analysis of blood culture data collected from ten sentinel AMR surveillance sites (tertiary hospitals) across Uganda between October 2020 and December 2023 to evaluate AMR patterns, identify resistance alerts, and missed AMR outbreaks. Blood culture data from 2,572 patients were analysed using WHONET-SaTScan software to generate isolate listing summaries, identify resistance alerts of public health importance, and detect spatial-temporal clusters that signal potential outbreaks of resistant bacteria. Results Bacterial growth was observed in 17.1% (441/2,572) of blood samples. The key isolated pathogens included <ns3:italic>Staphylococcus aureus</ns3:italic> 19.1% (86/441), Coagulase-negative <ns3:italic>Staphylococci</ns3:italic> 34.7% (153/441), and <ns3:italic>Escherichia coli</ns3:italic> 7.5% (33/441). Critical AMR alerts included 13.6% (60/441) cases of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales and 3.6% (16/441) carbapenem-resistant isolates, alongside high-priority resistance mechanisms such as methicillin-resistant <ns3:italic>Staphylococcus aureus</ns3:italic> (15/441) and vancomycin-resistant <ns3:italic>Enterococci</ns3:italic> 1.4% (6/441). Spatial-temporal analysis revealed seven significant clusters (possible outbreaks) across three sites, including a 12-day <ns3:italic>Enterococcus</ns3:italic> species cluster in a paediatric ward and a multi-ward <ns3:italic>Staphylococcus aureus</ns3:italic> outbreak. Conclusions This study reveals a significant burden of drug-resistant bloodstream infections in Ugandan hospitals and shows that key outbreak signals and possible outbreaks went unnoticed. Strengthening surveillance with real-time alerts, better data use, and targeted responses is critical to controlling the spread of resistant bacteria in Uganda and similar settings. </ns3:p>