Anti-microbial resistance (AMR) is one of the greatest global health threats. Countries with limited resources, such as Malawi, are particularly vulnerable to its impact, with resistant infections threatening to undo decades of medical progress. While antibiotics are a cornerstone of modern medicine, less than 2% of the 50,000 medical laboratories in 14 African countries, including Malawi, conduct bacteriology testing. Without definitive identification or susceptibility testing, antibiotics can be misused and overused for non-susceptible pathogens, further accelerating AMR.
Robert Krysiak, MSc, a clinical microbiologist at the Institute of Global Health and Infectious Diseases (IGHID) is leading an effort to assess antimicrobial stewardship activities at regional referral hospitals in Malawi and train local personnel to build long-term sustainable anti-microbial stewardship capacity in the country. The effort builds upon ongoing work to expand microbiology capacity that can improve detection and surveillance of AMR.
As UNC Project-Malawi’s Lab Director for 15 years, Krysiak’s deep expertise in laboratory systems has ensured research excellence for IGHID investigators with NIAID networks, focused on infectious diseases like HIV, Malaria and TB, as other subspecialty care has grown. Now, a pathology lab he helped establish services approximately 75 percent of the country’s pathology histology needs.
Fleming Fund Bolsters Lab Infrastructure
Historically, most antibiotics in Malawi have been prescribed without a diagnostic result, due to limited sampling, lab capacity, inadequate human resources and manual testing methods. But in January 2020, Krysiak started a new project to change this. The Fleming Fund provided the opportunity to establish the first large-scale microbiological study. Krysiak says UNC Project-Malawi had the right foundation for the project.
“The GSK malaria vaccine trial had laid the groundwork for microbiological studies. It required that we monitor blood cultures for a pediatric population, looking for co-infection or anything that might affect the outcome of the vaccine, and blood culture machines were brought in to monitor patient cultures. Since then, we’ve been building bacteriology capacity within UNC Project-Malawi, as well as supporting microbiology departmental growth at the Kamuzu Central Hospital Laboratory.”
It was this spirit of capacity building within UNC Project-Malawi that Fleming Fund representatives appreciated.
Malawi Recognized for Performance Success
In the first phase of the grant, significant infrastructure was improved in a One Health approach to providing 11 fully functional microbiology departments in human and animal health. This included the National Microbiology Reference Lab (NMRL), the Central Veterinary Laboratory (CVL), as well as support for the Antimicrobial Resistance National Coordinating Committee (AMRNCC). Site antimicrobial stewardship (AMS) committees were capacitated at several central and district hospitals, and by the end of Phase I, each lab was able to produce antibiograms and share this data with local stewardship committees at the site level and make informed treatment decisions. The country grant team did so well that Fleming Fund representatives from London made their single country visit to Malawi as part of a Phase I wrap-up.
As Phase II of the country grant began, in January 2024, Malawi was further recognized in its continued progress during a lead-in event prior to the High-Level Meeting on AMR in New York at the United Nations General Assembly meeting last September. The meeting led by Professor Dame Sally Davies, whose recognition of the importance in addressing AMR led to the creation of the Fleming Fund, was attended by representatives of the Malawi government and Robert Krysiak, on behalf of the grantee team.
Strengthening Site Antimicrobial Stewardship (AMS) Committees
Site-specific AMS committees, comprised of clinicians and pharmacists, help guide the proper use of antibiotics based on locally gathered data that is also being compiled to a national data repository at the Public Health Institute of Malawi (PHIM). This effort is managed through a software system that stores bacteriology data, to help guide labs on the entry of their cultures and enables national-level analysis.
“There are two critical platforms in use, the first being WHONET which is a database software the lab uses to manage patient samples towards recording bacterial identification and antimicrobial susceptibility testing results. Michael Owino worked with our Malawian colleague Dzinenani Maziya to create a national network where each lab is linked to a central server located at PHIM. Nightly all data is uploaded to the server allowing the AMRNCC to assess resistance patterns in real time.”
The second platform has been the creation of an interactive dashboard through the AMR National Data Collection System which has improved the collation of data across labs and will aid in disseminating information with the goal of assisting national level policy makers in making broader informed public health decisions.
Meanwhile, mentorship programs connect AMS committees from central hospitals with district hospitals.
“Technicians from rural areas get to see how AMS committees at central hospitals function, to understand what procedures should be in place and the linkages needed between clinic, laboratory, and pharmacy. Staff from the central hospitals are subsequently helping train personnel at the sentinel sites to ensure proper implementation while creating a communication flow that can build a strong national network.”
Krysiak says the initiative in Malawi is paving the way for similar AMR stewardship programs in other regions, demonstrating the power of data-driven decision-making and international cooperation in tackling AMR.
“Plans are being made for a Fleming Fund hosted webinar where our team will be able to present the dashboard to the other countries and discuss the development and refinement process as it is ongoing.”
By the end of the project, the team hopes to see improved AMS practices across the targeted hospitals, enhanced capacity for data-driven decision-making, and a sustainable model that can be replicated across the country.
A Multisectoral Collaboration with Pfizer and bioMérieux
In May 2024, the Malawi Ministry of Health, bioMérieux, and Pfizer formed a multi-sectoral collaboration to build antimicrobial stewardship capacity in the public sector, focused on infection prevention and control, diagnostics, surveillance, and to guide the appropriate use of antibiotics.
In this collaboration, bioMérieux equipped labs with a suite of new diagnostic and surveillance tools to help providers improve patient care, while helping the Ministry of Health analyze pathogens and susceptibility to antibiotics. Digital solutions focused on enhancing diagnostic capabilities, and developing robust information technology infrastructure has been central.
“Through bioMérieux, we are testing a laboratory linkage system called Maestria, which is software that helps bring the lab data more quickly to the mission. Sites are able to accurately identify an organism causing infection and treat it appropriately.”
Pfizer’s funding has further supplemented efforts to improve the functionality of the AMS committees, assist with updating the Standard Treatment Guidelines for Malawi, and finalize a National Action Plan on AMR.