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. 2021 Mar 8;11(3):e041418.
doi: 10.1136/bmjopen-2020-041418.

Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA)

Benon B Asiimwe #  1 , John Kiiru #  2 , Stephen E Mshana #  3 , Stella Neema  4 , Katherine Keenan  5 , Mike Kesby  6 , Joseph R Mwanga  7 , Derek J Sloan  8 , Blandina T Mmbaga  9 , V Anne Smith  10 , Stephen H Gillespie  8 , Andy G Lynch  8   11 , Alison Sandeman  8 , John Stelling  12 , Alison Elliott  13   14 , David M Aanensen  15   16 , Gibson E Kibiki  17 , Wilber Sabiiti  8 , Matthew T G Holden  8 ; HATUA Consortium
Collaborators, Affiliations

Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA)

Benon B Asiimwe et al. BMJ Open. .

Abstract

Introduction: Antimicrobial resistance (AMR) is a global health threat that requires urgent research using a multidisciplinary approach. The biological drivers of AMR are well understood, but factors related to treatment seeking and the social contexts of antibiotic (AB) use behaviours are less understood. Here we describe the Holistic Approach to Unravel Antibacterial Resistance in East Africa, a multicentre consortium that investigates the diverse drivers of drug resistance in urinary tract infections (UTIs) in East Africa.

Methods and analysis: This study will take place in Uganda, Kenya and Tanzania. We will conduct geospatial mapping of AB sellers, and conduct mystery client studies and in-depth interviews (IDIs) with drug sellers to investigate AB provision practices. In parallel, we will conduct IDIs with doctors, alongside community focus groups. Clinically diagnosed patients with UTI will be recruited from healthcare centres, provide urine samples and complete a questionnaire capturing retrospective treatment pathways, sociodemographic characteristics, attitudes and knowledge. Bacterial isolates from urine and stool samples will be subject to culture and antibiotic sensitivity testing. Genomic DNA from bacterial isolates will be extracted with a subset being sequenced. A follow-up household interview will be conducted with 1800 UTI-positive patients, where further environmental samples will be collected. A subsample of patients will be interviewed using qualitative tools. Questionnaire data, microbiological analysis and qualitative data will be linked at the individual level. Quantitative data will be analysed using statistical modelling, including Bayesian network analysis, and all forms of qualitative data analysed through iterative thematic content analysis.

Ethics and dissemination: Approvals have been obtained from all national and local ethical review bodies in East Africa and the UK. Results will be disseminated in communities, with local and global policy stakeholders, and in academic circles. They will have great potential to inform policy, improve clinical practice and build regional pathogen surveillance capacity.

Keywords: infection control; microbiology; public health; social medicine; urinary tract infections.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
ABR assemblage (a complex set of inter-related factors) as it refers to UTI. AB, antibiotic; ABR, antibiotic resistance; UTI, urinary tract infection.
Figure 2
Figure 2
Location of HATUA SAs. HATUA, Holistic Approach to Unravel Antibacterial Resistance in East Africa; SA, study area.
Figure 3
Figure 3
Description of quantitative and qualitative data collected about the self-reported ‘patient pathway’ in the linked patient sample. HATUA, Holistic Approach to Unravel Antibacterial Resistance in East Africa; UTI, urinary tract infection.
Figure 4
Figure 4
Linked individual-level patient dataset collected in HATUA. AB, antibiotic; AMR, antimicrobial resistance; AST, antibiotic sensitivity testing; ESBL, extended spectrum beta-lactam resistance; HATUA, Holistic Approach to Unravel Antibacterial Resistance in East Africa; MDR, multidrug resistance; UTI, urinary tract infection; WGS, whole-genome sequence.
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