Dear Editor,
Antimicrobial resistance (AMR) remains one of the most pressing global health challenges. As resistance outpaces new drug development, routine infections are increasingly difficult to treat. Misuse and overuse of antibiotics across human, animal, and environmental sectors drive resistance. In 2019, bacterial AMR was directly linked to approximately 1.27 million deaths and contributed to an estimated 4.95 million deaths worldwide. 1, 2
Within this global context, Rwanda faces a growing AMR burden, particularly in tertiary care settings, driven by high resistance among gram-negative bacteria such as Escherichia coli and Klebsiella pneumoniae. These pathogens show near-universal resistance to amoxicillin–clavulanate and only 27% susceptibility to ceftriaxone, with widespread extended-spectrum β-lactamase phenotypes further limiting treatment options and increasing mortality and hospitalization. Reference Bizimungu, Crook, Babane and Bitunguhari3 Contributing factors include inadequate infection prevention, environmental contamination, extensive antibiotic use in livestock, and limited access to clean water, sanitation, vaccines, and diagnostics. Surveillance is largely limited to tertiary centers, while inconsistent diagnostics, absence of antimicrobial stewardship programs, lack of therapeutic drug monitoring, and insufficient prescriber training promote empiric broad-spectrum antibiotic use and impede evidence-based guideline development. Reference Bizimungu, Crook, Babane and Bitunguhari3
A point prevalence survey by Igizeneza et al. at the University Teaching Hospital of Kigali found that 39.3% of hospitalized patients received at least one antimicrobial, with 65.1% classified under the World Health Organization AWaRe “Watch” category. Stop or review dates were documented in 10.4% of cases, surgical prophylaxis exceeded recommended duration in 83.3%, and cultures were obtained for 27.1% of patients receiving antibiotics. Reference Igizeneza, Bitunguhari and Masaisa4
Recommended stewardship interventions include implementing multidisciplinary hospital-based programs, expanding laboratory capacity for routine culture and susceptibility testing, strengthening prescriber education, restricting prolonged surgical prophylaxis, and enhancing community engagement. Systematic reviews and meta-analyses support locally adapted stewardship efforts, demonstrating improved prescribing practices and reduced resistance in comparable settings. Reference Bizimungu, Crook, Babane and Bitunguhari3
Train-the-Trainer programs
Train-the-Trainer (TTT) programs establish cross-regional partnerships between healthcare institutions and equip trainees with clinical knowledge and skills to address gaps in antimicrobial stewardship. The model promotes sustainability by enabling trainees to mentor additional healthcare providers, thereby expanding program reach. Reference Goff, Bauer and Brink5
Between 2013 and 2019, TTT initiatives in South Africa enabled pharmacists to lead over 40,000 stewardship interventions across 60 hospitals, improving patient outcomes and addressing workforce shortages by expanding pharmacists’ clinical roles. These programs supported research and quality improvement, including optimization of surgical prophylaxis, appropriate use of linezolid and colistin, early antimicrobial administration, pharmacist-led electronic stewardship initiatives, and reductions in antimicrobial consumption measured by defined daily doses. Reference Goff, Bauer and Brink5 Trainee involvement in data collection and publication further strengthened the stewardship evidence base.
Globally, TTT programs represent a scalable model for strengthening health systems and advancing antimicrobial stewardship through structured mentorship and knowledge transfer. Reference Goff, Bauer and Brink5
A global stewardship alliance
To inform future Train-the-Trainer (TTT) initiatives, clinical pharmacists and students from the University of Florida College of Pharmacy and UF Health Shands Hospital partnered with providers from the University of Rwanda and the University Teaching Hospital of Kigali. In December 2023, UF specialists hosted a physician and pharmacist from Rwanda to launch the TTT program. Preparatory virtual sessions focused on capacity building, including microbiology laboratory capabilities and implementation of antimicrobial stewardship strategies such as development of standard treatment guidelines, optimization of antibiotic selection and duration, improved documentation, incorporation of culture-based decision-making, and monitoring antimicrobial use and resistance trends. During the onsite visit, participants engaged in hands-on training and discussions on integrating these practices into routine clinical workflows.
UF specialists provided targeted instruction on stewardship program structure and key components, including leadership engagement, multidisciplinary committees, and pharmacist- or physician-led oversight. Training included development and interpretation of antibiograms, hospital-specific infectious diseases protocols, therapeutic drug monitoring, and review of restricted antimicrobial policies, including prospective audit and feedback and preapproval processes. Trainees participated in clinical rounds with stewardship pharmacists, while faculty from Rwanda presented institutional practices and workflows, fostering bidirectional knowledge exchange.
Following the program, in October 2024, the American Pharmacists Association–Academy of Student Pharmacists (APhA-ASP) Infectious Disease Committee at UF College of Pharmacy hosted a virtual presentation by Rwandan providers titled Clinical Practice and Antimicrobial Stewardship in Rwanda. Students engaged by posing questions and reflecting on regional stewardship challenges, while contributing perspectives on US surgical site infection prophylaxis to inform guideline development at the University of Rwanda. This exchange promoted an interactive learning environment and sharing of local healthcare insights.
Building on prior work, the APhA-ASP Policy Committee at the University of Tennessee College of Pharmacy implemented initiatives to reduce antibiotic overuse through targeted education, interprofessional collaboration, and enhanced surveillance of antibiotic use and resistance. Student pharmacists promoted stewardship awareness through educational activities at the 2024 APhA-ASP Midyear Regional Meeting. Coursework and interprofessional case discussions reinforced the pharmacist’s role in antimicrobial stewardship and supported evidence-based prescribing. Ongoing collaborations with local health organizations advance infection prevention efforts and align with APhA-ASP’s mission to promote patient safety and public health.
From partnership to global impact: the path forward
Looking ahead, expanded collaboration may enhance peer-to-peer learning through virtual exchanges and study abroad opportunities, fostering globally minded clinicians. Exchange programs can provide direct exposure to international healthcare systems and collaborative practices while supporting development of hospital-specific protocols and locally led research. This model is scalable to other teaching hospitals across Africa, strengthening networks and advancing antimicrobial stewardship. By equipping future pharmacists with tools to critically evaluate prescribing, these programs address key drivers of inappropriate antibiotic use, including patient demand, time constraints, and gaps in clinical education.
Acknowledgements
None.
Financial support
This initiative was supported by funding from the University of Florida College of Pharmacy and the University of Rwanda.
Competing interests
All authors report no conflicts of interest relevant to this article.
Ethical standard
Ethics approval was not required for this report, as it did not involve human participants, identifiable data, or animal subjects.
