Antimicrobial Resistance (AMR): Causes, Prevention & EMT Notes

Table of Contents

Antimicrobial Resistance (AMR): Mechanisms, Causes, Clinical Impact and Stewardship

Why this lesson matters: Emergency teams cannot safely assume that every fever needs an antibiotic or that a familiar antibiotic will work. Antimicrobial resistance can turn an ordinary infection into sepsis, prolong illness, increase complications and close the treatment options available to the next patient. Every emergency medical technician contributes to AMR prevention through accurate assessment, timely specimens, infection prevention, safe administration, patient education and careful handover.

Learning outcomes

By the end of this lesson, the emergency medicine student should be able to:

Define antimicrobial, antimicrobial resistance, multidrug resistance, antibiotic susceptibility and antimicrobial stewardship.
Distinguish antibiotic resistance in bacteria from resistance involving viruses, fungi and parasites.
Explain how microorganisms acquire and spread resistance through mutation, selection and horizontal gene transfer.
Describe major mechanisms of resistance, including drug inactivation, target modification, reduced permeability, efflux and pathway protection.
Identify patient, prescriber, health-facility, community, agricultural and environmental drivers of AMR.
Recognise the clinical, economic and public-health consequences of resistant infection.
Apply emergency assessment principles to a patient with suspected severe or resistant infection.
Explain how cultures, susceptibility testing, antibiograms and surveillance support rational antimicrobial selection.
Describe antimicrobial stewardship interventions: prevention, diagnostic stewardship, right drug, dose, route, timing, duration, review and de-escalation.
Use infection-prevention measures and communication strategies to reduce transmission and unnecessary antimicrobial exposure.
Discuss Uganda’s One Health AMR response and the role of emergency medical personnel.

1. What are antimicrobials?

Antimicrobials are medicines or substances that prevent the growth of, inhibit or kill microorganisms. The term includes antibiotics, antivirals, antifungals and antiparasitic medicines. An antibiotic specifically targets bacteria; it does not treat viral influenza, most common colds or other non-bacterial illnesses.

Group	Target	Examples of infections or conditions	Emergency relevance
Antibacterials/antibiotics	Bacteria	Pneumonia, meningitis, urinary infection, wound infection and sepsis when bacterial infection is suspected.	Wrong selection or delay can be fatal; unnecessary use drives resistance.
Antivirals	Viruses	Selected influenza, HIV, hepatitis, herpes and other viral diseases.	Effect is often time-dependent and diagnosis-specific; antibiotics are not substitutes.
Antifungals	Fungi	Candidiasis, cryptococcosis, dermatophyte and invasive fungal infection.	Many are toxic or interact with emergency medicines; confirmation and monitoring matter.
Antiparasitics	Protozoa, helminths and ectoparasites	Malaria, amoebiasis, schistosomiasis, helminth infections and scabies.	Species, severity, pregnancy and organ function influence treatment.
Antiseptics	Microorganisms on living tissue	Skin and mucosal preparation or wound care.	Correct concentration and contact time are required; not all are safe to swallow or inject.
Disinfectants	Microorganisms on non-living surfaces	Environmental and equipment decontamination.	They are not systemic medicines and may be toxic if used on patients.

2. Definition of antimicrobial resistance

Antimicrobial resistance (AMR) occurs when microorganisms change or acquire traits that allow them to survive exposure to medicines that would previously inhibit or kill them. The organism—not the patient—becomes resistant. A person may carry a resistant organism without symptoms and can transmit it to another person.

WHO describes AMR as a situation in which bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines, making infections difficult or sometimes impossible to treat. This increases the risk of spread, severe illness, disability and death.

Do not say “the patient is resistant.” Say “the infection is caused by a resistant organism” or “the isolate is resistant to [medicine].” The patient may have an immune problem, poor drug exposure, a wrong diagnosis or treatment failure without the organism being genetically resistant.

Important terms

Term	Meaning	Example
Susceptible	The organism is likely to respond to an antimicrobial at achievable exposure using the tested method and standard dose.	A urine isolate is susceptible to the recommended oral medicine.
Intermediate or increased exposure	The result may require higher exposure, altered dosing or a specific site of infection to achieve success.	A medicine may work when the dose or infusion strategy is optimised.
Resistant	The organism is unlikely to respond to the tested antimicrobial at usual exposure.	A bloodstream isolate is resistant to the initial antibiotic.
Intrinsic resistance	A natural characteristic of a species that makes a medicine ineffective.	A drug may have no useful target in that organism.
Acquired resistance	Resistance gained through mutation or genetic material from another organism.	A bacterium acquires a plasmid encoding an inactivating enzyme.
Multidrug-resistant (MDR)	Resistance to several antimicrobial classes, according to the organism-specific definition.	TB resistant to key first-line medicines or a hospital pathogen resistant to multiple classes.
Extensively drug-resistant (XDR)	Resistance to most available classes, leaving very limited options.	Some MDR organisms retain susceptibility to only a few reserve medicines.
Pandrug-resistant (PDR)	Resistance to all agents in all relevant antimicrobial categories tested.	A rare but critical situation requiring specialist and infection-control action.
Colonisation	Organisms are present and may multiply without causing disease.	Carriage of resistant bacteria on skin or in the nose.
Infection	Microorganisms invade or multiply with tissue response and clinical signs or symptoms.	Fever, pyuria, pneumonia or wound infection with a compatible pathogen.
Antibiogram	A summary of local susceptibility patterns for common organisms and medicines.	Guides empiric choices while awaiting the individual patient’s result.

3. Why AMR is a major emergency-medicine concern

Delayed effective treatment: sepsis, meningitis, pneumonia and wound infection can deteriorate while the initial medicine is ineffective.
Fewer treatment choices: clinicians may need medicines that are more toxic, expensive, unavailable or difficult to administer.
Longer admission: resistant infections often require prolonged monitoring, isolation, procedures and intravenous treatment.
More complications: organ failure, abscess formation, treatment failure, recurrent infection and disability become more likely.
Transmission in crowded settings: ambulances, emergency departments, wards, households and communities can spread resistant organisms.
Higher procedure risk: surgery, chemotherapy, dialysis, intensive care and care of premature infants become less safe when infections cannot be treated.
Public-health impact: resistance crosses borders and moves between humans, animals, food, water, soil and healthcare facilities.

Emergency example: A patient with septic shock received an antibiotic from a previous clinic but is now worse. The correct response is not simply to repeat the same medicine. Reassess ABCDE, obtain cultures when this will not delay life-saving treatment, check the dose/route/timing and local resistance data, escalate for senior review and ensure source control.

4. The difference between antimicrobial resistance and treatment failure

Treatment failure is a clinical outcome; resistance is one possible cause. Before labelling an infection resistant, assess whether the problem is a wrong diagnosis, poor adherence, inadequate dose, wrong route, poor absorption, delayed administration, drug interaction, inadequate source control, an inaccessible infected site, immunosuppression or a laboratory error.

Possible reason for failure	Clues	Action
True resistance	Culture and susceptibility show non-susceptibility; patient remains unwell despite adequate exposure.	Escalate for targeted treatment and infection-control advice.
Wrong diagnosis	Signs suggest malaria, viral illness, trauma, inflammatory disease or non-infectious shock.	Reassess diagnosis and avoid adding unnecessary antibiotics.
Inadequate dose or interval	Under-dosing, missed doses, weight change or renal adjustment error.	Verify order, calculation, administration record and organ function.
Poor absorption	Vomiting, diarrhoea, ileus, malabsorption or reduced consciousness.	Use an authorised reliable route and monitor exposure.
Drug interaction	New medicine, food, antacid, enzyme inducer/inhibitor or herbal product.	Review the complete medication history.
Delayed treatment	Long interval between recognition, prescription, dispensing and administration.	Improve emergency workflow and document delays.
Inadequate source control	Abscess, obstructed urinary tract, infected device, necrotic tissue or retained foreign body.	Seek drainage, removal, decompression or surgical review.
Host factors	Neutropenia, HIV, diabetes, malnutrition, burns or severe organ disease.	Escalate early and coordinate supportive care.

5. One Health and the AMR ecosystem

AMR is not only a hospital problem. The same resistance genes and organisms can move through people, animals, food, water, soil and the environment. Human antimicrobial use, veterinary use, agricultural practices, pharmaceutical waste, sanitation and infection prevention all influence the overall risk.

One Health lens: human health + animal health + food systems + environment + water/sanitation + health systems + governance.

Resistant organisms can spread from household members, healthcare workers, patients, animals or contaminated surfaces.
Antimicrobials used in livestock and aquaculture can select resistant organisms and genes.
Inadequate waste disposal can expose communities and the environment to antimicrobials and resistant organisms.
Unsafe water, poor sanitation and overcrowding increase transmission and the need for treatment.
AMR surveillance is strongest when clinical, veterinary, laboratory, pharmacy, agriculture and environmental data are connected.

6. How resistance develops

Resistance is an evolutionary process. A microbial population may contain a small number of organisms with a resistance trait before treatment begins. When an antimicrobial is used, susceptible organisms are inhibited or killed while resistant organisms survive, multiply and become more common. Antimicrobial exposure does not “teach” every organism to resist in a deliberate way; it creates selection pressure that favours organisms already carrying or acquiring useful traits.

6.1 Mutation and selection

Microorganisms reproduce rapidly and copy genetic material. Random changes can alter a drug target, a membrane, an enzyme or a regulatory pathway. If the change helps survival in the presence of a medicine, that organism has a selective advantage. Incomplete treatment, repeated exposure and high transmission allow the resistant population to persist.

6.2 Horizontal gene transfer

Mechanism	How it happens	Why it matters
Conjugation	Direct transfer of plasmid DNA between connected bacterial cells.	Can spread several resistance genes together, including across species.
Transformation	A bacterium takes up free DNA fragments from its environment.	DNA released from dead bacteria may be incorporated into a new host.
Transduction	A bacteriophage carries bacterial DNA from one cell to another.	Resistance genes can move during viral infection of bacteria.
Transposons/integrons	Mobile genetic elements move resistance genes within or between DNA molecules.	Several mechanisms can be assembled and transferred as a package.

7. Major mechanisms of antimicrobial resistance

Mechanism	What the organism changes	Clinical consequence
Drug inactivation	Produces enzymes that break down or chemically modify the medicine.	The antimicrobial reaches the organism but is destroyed or neutralised.
Target modification	Changes the structure or amount of the cellular target.	The medicine binds poorly or cannot interrupt the essential process.
Reduced permeability	Removes, changes or closes channels through which the medicine enters.	Less medicine reaches the intracellular target.
Efflux pump	Actively pumps the medicine out of the cell.	Intracellular concentration remains below the effective level.
Metabolic pathway bypass	Uses an alternative biochemical route or obtains the product from another source.	Blocking one pathway no longer stops growth.
Biofilm formation	Organisms live in a protective matrix attached to a surface.	Reduced penetration, altered metabolism and persistent device-related infection.
Target protection	Protective proteins shield or replace the drug target.	The antimicrobial may bind but the vital function continues.

Examples of resistance mechanisms students should recognise

Beta-lactamase production: enzymes hydrolyse the beta-lactam ring of susceptible medicines; extended-spectrum enzymes may affect several cephalosporins.
Altered penicillin-binding proteins: the target changes so beta-lactams bind less effectively.
Reduced porin entry: fewer channels reduce penetration of certain medicines into Gram-negative bacteria.
Macrolide target modification: ribosomal binding sites are altered, reducing inhibition of protein synthesis.
Fluoroquinolone target mutation: changes in DNA gyrase or topoisomerase reduce binding.
Efflux: active transporters remove tetracyclines, macrolides, fluoroquinolones or other agents.
Biofilm-associated tolerance: organisms in catheters, wounds or prostheses may be difficult to eradicate without source control.

8. Drivers of antimicrobial resistance

AMR is driven by a combination of microbial evolution, antimicrobial exposure, transmission and weak systems. Blaming one patient or one prescriber hides the preventable conditions that need correction.

8.1 Patient and community drivers

Buying antimicrobials without an appropriate assessment or prescription.
Using leftover medicines, sharing medicines or taking a relative’s treatment.
Stopping when symptoms improve, missing doses or stretching doses to save money.
Taking antibiotics for viral colds, uncomplicated symptoms or non-infectious conditions.
Using poor-quality, expired, falsified or substandard products.
Self-medication with multiple medicines or mixing pharmaceuticals with unverified remedies.
Delayed presentation because of cost, distance, stigma, transport or limited trust.
Poor hand hygiene, unsafe water, inadequate sanitation, overcrowding and poor food hygiene.

8.2 Prescriber and health-worker drivers

Prescribing without adequate examination, differential diagnosis or diagnostic support.
Using broad-spectrum therapy when a narrower effective medicine is appropriate.
Failing to obtain cultures when indicated or failing to review the results.
Incorrect dose, interval, route, duration or adjustment for renal/liver function.
Continuing therapy without a documented indication or review date.
Giving antibiotics for patient pressure, diagnostic uncertainty or habit without safety-netting.
Not documenting the medicine, last dose, response, allergy or culture result at handover.
Using outdated guidelines or relying on memory when local resistance patterns have changed.

8.3 Facility and health-system drivers

Weak infection prevention and control, overcrowded rooms or inadequate isolation.
Insufficient laboratory capacity, delayed results or no local antibiogram.
Interrupted medicine supply causing substitution, incomplete courses or use of poor-quality products.
Unregulated access, poor storage, cold-chain failure or weak stock control.
Staff shortages, fatigue, interruptions and poor communication across transitions of care.
Weak antimicrobial stewardship governance, audit and feedback.
Limited access to vaccines, clean water, diagnostics and appropriate medicines.

8.4 Animal, food and environmental drivers

Antimicrobial use in livestock, poultry, fish and companion animals.
Routine or preventive use without veterinary assessment and monitoring.
Contaminated food, animal contact, slaughter environments and agricultural runoff.
Improper disposal of unused antimicrobials, animal waste, hospital waste or pharmaceutical effluent.
Movement of workers, animals, food and goods across districts and borders.

Key principle: every unnecessary antimicrobial course creates exposure without benefit. Every preventable infection avoided through vaccination, hand hygiene, safe water, source control and IPC is an antimicrobial course that may not be needed.

9. Antimicrobial exposure and selection pressure

Selection pressure increases when an antimicrobial is present at a site where microorganisms are exposed but susceptible organisms are not fully eliminated. The risk is influenced by the drug’s spectrum, concentration, tissue penetration, duration, adherence and the microbial population.

Exposure problem	How it can select resistance	Prevention
Unnecessary use	Exposes normal flora and colonising organisms without treating a bacterial disease.	Confirm indication and use delayed/alternative management when safe.
Too low a dose	May suppress susceptible organisms without achieving effective exposure.	Use weight, organ function, route and protocol-specific dosing.
Too long a course	Extends selection pressure after the infection is controlled.	Set a review/stop date and use the shortest effective duration.
Too broad a spectrum	Disrupts more normal flora and selects resistance across several organisms.	Choose the narrowest effective medicine after diagnostic review.
Interrupted supply or adherence	Leads to missed doses and treatment failure; the exact effect varies by medicine and infection.	Address access, side effects, understanding and follow-up rather than giving simplistic advice.
Poor tissue penetration	Effective plasma concentration may not reach the infected site.	Review site, source control, route and specialist guidance.

10. Clinical presentation of resistant infection

Resistance does not create one unique symptom pattern. A resistant infection may look like an ordinary infection at first. Suspicion rises when the patient fails to improve despite adequate treatment, has a history of resistant organisms, has repeated healthcare exposure or is in a setting where resistant pathogens are common.

Features that should raise concern

Persistent or worsening fever, tachycardia, tachypnoea, hypotension, confusion or reduced urine output despite treatment.
Progression of an infection while receiving an apparently appropriate medicine.
Previous culture showing a resistant organism or recent admission, surgery, dialysis or intensive-care stay.
Recent antimicrobial exposure, especially repeated broad-spectrum therapy.
Residence in or transfer from a facility with known outbreaks or high resistance rates.
Recurrent urinary, wound, respiratory or bloodstream infection with repeated treatment failure.
Indwelling catheter, vascular device, tracheostomy, prosthesis, chronic wound or other biofilm risk.
Immunosuppression, severe malnutrition, burns, HIV, diabetes or advanced organ disease.

Do not wait for the laboratory report to recognise danger. A patient with suspected sepsis needs immediate ABCDE assessment, resuscitation, source evaluation and timely clinician-led antimicrobial decisions. AMR changes the choice and review process; it does not justify delaying life-saving stabilisation.

11. Emergency assessment of suspected serious infection

Recognise danger: assess airway, breathing, circulation, disability, exposure, temperature, perfusion and mental status.
Identify possible infection: lungs, urinary tract, abdomen, skin/soft tissue, central nervous system, bloodstream, reproductive tract, bone/joint or device.
Estimate severity: hypotension, altered consciousness, hypoxia, oliguria, high work of breathing, mottling, delayed capillary refill and rapidly progressive disease require urgent escalation.
Ask about antimicrobial exposure: medicine, dose, route, start date, missed doses, recent courses, allergies and prior cultures.
Ask about healthcare exposure: recent admission, surgery, dialysis, device, long-term care, travel and known contact with resistant organisms.
Obtain appropriate specimens: cultures should be collected before antimicrobial therapy when feasible and should not delay resuscitation or time-critical treatment.
Support physiology: oxygen when indicated, vascular access, fluids/vasopressors, glucose management, analgesia, temperature control and monitoring under protocol.
Start source control: look for an abscess, obstructed system, infected device, necrotic tissue or retained foreign body.
Communicate: give a structured handover with suspected source, severity, exposures, allergies, specimens, medicine and response.

Specimens and diagnostic stewardship

Specimen principle	Why it matters	Common error
Collect from the correct site	Improves the chance that the result represents the infection rather than colonisation.	Swabbing a superficial area when a deep specimen is needed.
Use aseptic technique	Reduces contamination and false-positive results.	Contaminated blood culture leading to unnecessary antibiotics.
Collect before antimicrobials when feasible	Improves yield and helps later narrowing of therapy.	Delaying an unstable patient while trying to obtain every test.
Label accurately	Links result to patient, site and collection time.	Unlabelled or incorrectly labelled specimen.
Transport promptly	Preserves organism viability and result reliability.	Specimen left on a trolley or exposed to unsuitable temperature.
Interpret with clinical findings	Separates infection from colonisation or contamination.	Treating a positive colonisation result without compatible illness.

12. Antimicrobial stewardship

Antimicrobial stewardship (AMS) is a coordinated approach that promotes the best possible clinical outcome while minimising toxicity, unnecessary exposure, resistance and cost. Stewardship is not withholding treatment from a sick patient; it is ensuring that treatment is justified, timely, targeted, correctly dosed and reviewed.

WHO describes stewardship programmes as a core strategy against AMR and identifies interventions that can be adapted to low-resource facilities.

Emergency AMS — START, REVIEW, REFINE:
START when indicated and time-critical; REVIEW diagnosis, cultures, dose, route and response; REFINE by stopping, narrowing, changing or switching route when evidence supports it.

The “right” antimicrobial decision

Decision	Questions
Right patient	Is there evidence of infection in this patient, and what are the risks of treatment?
Right diagnosis	Is the syndrome bacterial, viral, fungal, parasitic, inflammatory, traumatic or non-infectious?
Right drug	Which medicine covers the likely pathogen and site based on guideline, local data and patient factors?
Right dose	Does the dose achieve effective exposure for weight, age, organ function, severity and site?
Right route	Can the patient absorb oral treatment, or is IV/another route required initially?
Right timing	Should it be given immediately, after cultures, before a procedure or at a specific interval?
Right duration	What is the intended course and review/stop date?
Right review	Who will check response, culture, toxicity, allergy, organ function and ongoing indication?
Right communication	Does the patient understand adherence, side effects, follow-up and when to return?

Core stewardship interventions

Guideline-based empiric therapy: use current national, facility and syndrome-specific guidance.
Prospective audit and feedback: review prescriptions and provide constructive recommendations.
Formulary restriction or pre-authorisation: reserve selected agents for defined indications and senior approval.
Antibiotic time-out: review the indication, culture, dose, route and duration after an agreed interval.
De-escalation: narrow spectrum or stop when results and clinical response permit.
IV-to-oral switch: change route when the patient is stable, absorbing and an effective oral option exists.
Dose optimisation: adjust for weight, renal/liver function, pharmacokinetics, infection site and severity.
Diagnostic stewardship: order, collect, label and interpret tests that can answer the clinical question.
Education and feedback: train prescribers, nurses, pharmacists, EMTs, patients and caregivers.
Surveillance and reporting: use resistance, antimicrobial-use and outcome data to improve practice.

13. Empiric, targeted and prophylactic therapy

Therapy type	When used	Stewardship rule
Empiric therapy	Before the pathogen and susceptibility are known, based on syndrome, severity, local data and patient risks.	Review when culture, imaging and clinical response become available.
Targeted/definitive therapy	After a pathogen and susceptibility pattern are available, or the diagnosis is sufficiently established.	Use the narrowest effective option at the correct exposure.
Prophylaxis	Prevention of a defined infection in a defined high-risk situation.	Use correct timing and duration; prophylaxis is not treatment of an established infection.
Suppressive therapy	Long-term reduction of recurrence when eradication is not possible.	Requires specialist indication, monitoring and review for resistance and toxicity.

14. De-escalation, escalation and treatment review

De-escalate: narrow spectrum, stop duplicate coverage, change IV to oral or stop when infection is not supported.
Escalate: seek senior/ID/microbiology advice when the patient deteriorates, the organism is resistant, the source is unclear or the current medicine is ineffective.
Continue: only when the diagnosis, response and risk–benefit assessment support ongoing treatment.
Change route: when circulation, absorption, organ function or clinical stability changes.
Change dose: when weight, renal/liver function, therapeutic monitoring or susceptibility requires it.
Control the source: antibiotics cannot replace drainage, debridement, device removal or relief of obstruction when those are needed.

15. Infection prevention and control (IPC) to prevent AMR

WHO identifies strong infection prevention and control as one of the most effective ways to control the spread of AMR: every infection prevented is an antimicrobial course avoided.

Standard precautions

Perform hand hygiene at the correct moments and technique.
Use gloves, gowns, masks, eye protection and other PPE according to exposure risk.
Clean and disinfect equipment between patients according to product and contact-time instructions.
Use safe injection practices; never reuse needles, syringes or single-dose vials between patients.
Dispose of sharps, dressings, body fluids and contaminated materials correctly.
Use respiratory hygiene, cough etiquette and appropriate masking during respiratory illness.
Clean reusable airway, suction, oxygen and transport equipment before reuse.

Transmission-based precautions

Precaution	Used when	Emergency actions
Contact	Organisms spread through direct or indirect contact.	Gloves/gown as indicated, dedicated equipment, environmental cleaning and cohorting/isolation.
Droplet	Large respiratory droplets are a major route.	Mask, source control, distance, ventilation and patient placement.
Airborne	Small particles remain suspended and travel through air.	Appropriate respirator, ventilation/airborne room and minimise unnecessary movement.
Protective environment	Patient is highly vulnerable to infection.	Strict hand hygiene, environmental controls and careful staff/visitor screening.

Device and procedure safety

Insert urinary, vascular and airway devices only when indicated and remove them as soon as no longer needed.
Use aseptic non-touch technique and maintain closed systems where appropriate.
Inspect wounds, drains and insertion sites at every handover.
Do not give prophylactic antibiotics as a substitute for sterile technique.
Clean and disinfect transport surfaces after a patient with a resistant organism or body-fluid contamination.

16. Diagnostic stewardship and laboratory reporting

Diagnostic stewardship means using tests in a way that improves clinical decisions and reduces unnecessary antimicrobial exposure. A test should answer a clinical question and its result should be available to the team that must act on it.

Laboratory element	What it tells the team	Limitations
Microscopy/Gram stain	Early information about organism type, inflammatory cells or specimen quality.	May be unavailable, insensitive or affected by prior treatment.
Culture	Identifies organisms that grow under the test conditions.	A negative result does not always exclude infection.
Susceptibility testing	Estimates whether an isolate is susceptible, intermediate/increased exposure or resistant.	Must be interpreted with site, dose, achievable exposure and clinical response.
Rapid molecular test	Detects selected organisms or resistance genes quickly.	Detecting DNA may not equal active infection or viable organisms.
Local antibiogram	Summarises facility or district susceptibility patterns.	May not represent every ward, patient group or current outbreak.
AMR surveillance	Tracks trends over time and supports policy, procurement and IPC.	Requires reliable sampling, laboratory quality and reporting.

17. Uganda’s AMR response

Uganda’s Ministry of Health publishes a national AMR action plan and supports a One Health response involving human health, animal health, agriculture, laboratories, pharmacies, environment and communities. The Ministry’s current AMR resources should be checked alongside facility guidelines and the current National Standard Treatment Guidelines.

Priority areas for Uganda’s health workers

Awareness and education: explain when antimicrobials are needed, how to take them safely and why sharing or saving leftovers is harmful.
Infection prevention: improve hand hygiene, cleaning, PPE, safe injections, isolation, vaccination and environmental sanitation.
Surveillance: collect quality specimens and report resistance, outbreaks, medicine use and adverse events.
Stewardship: follow national/facility guidelines, review therapy and use local laboratory data.
Access and quality: support availability of effective, quality-assured antimicrobials, diagnostics and vaccines.
One Health coordination: recognise connections among hospitals, communities, livestock, food systems and water.
Governance: participate in antimicrobial committees, audit, feedback, training and accountability.

Uganda-focused EMT contribution: record the medicine and last dose during referral, communicate prior cultures and allergies, prevent contamination during transport, avoid casual antibiotic advice, use PPE, collect specimens correctly and escalate suspected resistant infection early.

18. AMR in the emergency department and ambulance

Before arrival or at triage

Ask about recent admission, surgery, dialysis, antibiotics, cultures, resistant organisms and infection-control alerts.
Use source control and respiratory hygiene at the entrance for coughing or febrile patients.
Separate patients with suspected transmissible infection when possible and notify the receiving area.

During transport

Use appropriate PPE and clean high-touch surfaces between patients.
Keep specimens, medication charts, allergy information and last-dose times with the patient.
Do not start, stop or switch antimicrobials outside protocol; communicate concerns to the responsible clinician.
Use safe sharps disposal and avoid contaminating oxygen, suction, monitors or stretcher surfaces.

At handover

Handover item	What to say
Situation	Suspected source, severity, current vital signs and immediate risks.
Background	Recent healthcare exposure, antibiotics, cultures, devices, comorbidities and allergies.
Assessment	Clinical findings, specimens collected, oxygen/fluids, dose/route/time of medicine and response.
Recommendation	Pending results, isolation/PPE needs, next due dose, monitoring and escalation concerns.

19. Special clinical situations

Sepsis and septic shock

AMR risk does not change the need for immediate recognition and physiological support.
Obtain cultures where feasible without delaying resuscitation or time-critical treatment.
Use authorised empiric guidance that considers local resistance, previous cultures and recent antimicrobial exposure.
Review within the defined time window; narrow, change or stop when evidence supports it.
Look actively for source-control needs such as drainage or device removal.

Meningitis or severe central nervous system infection

Prioritise airway, breathing, circulation, seizures, glucose and urgent clinician-led treatment.
Do not delay time-critical treatment for a procedure that is unsafe or unavailable.
Communicate recent antibiotics, resistant organisms, travel and healthcare exposure.

Pneumonia and respiratory infection

Distinguish bacterial disease from viral infection, asthma, heart failure, aspiration or pulmonary embolism.
Use respiratory isolation and source control; assess oxygenation and work of breathing.
Review antibiotic response and culture/imaging results rather than automatically adding a second medicine.

Urinary infection and catheter-associated infection

Separate asymptomatic bacteriuria or colonisation from a symptomatic infection needing treatment.
Collect an appropriate specimen before treatment when feasible and assess obstruction or device complications.
Remove or replace an unnecessary catheter according to clinical guidance.

Wounds, burns and diabetic foot infection

Clean, assess depth and obtain appropriate specimens; superficial swabs may not represent deeper infection.
Look for abscess, necrosis, foreign body, osteomyelitis, poor perfusion or need for debridement.
Do not use prolonged antibiotics as a substitute for wound care, off-loading, drainage or surgery.

20. Patient and caregiver education

Explain that antibiotics treat selected bacterial infections and do not treat most viral colds or flu.
Explain the exact dose, route, timing, duration and what to do if a dose is missed or vomited.
Tell the patient not to share, save, sell or use leftover antimicrobials.
Explain common adverse effects and urgent symptoms such as breathing difficulty, facial swelling, severe rash, persistent vomiting or severe diarrhoea.
Use teach-back: ask the patient to repeat the plan in their own words.
Discuss adherence and access barriers without blame; arrange follow-up or referral when possible.
Encourage vaccination, hand hygiene, safe water, food hygiene, safer sex and appropriate wound care.
Tell the patient when to return urgently: worsening fever, confusion, breathlessness, reduced urine, persistent vomiting, severe pain or inability to take treatment.

Communication example: “This medicine is being used because your assessment suggests a serious bacterial infection. We will review the results and your response. Do not share it or save it for another illness. Tell us immediately if you develop breathing difficulty, swelling, a severe rash, persistent diarrhoea or worsening weakness.”

21. AMR prevention checklist for emergency personnel

At every patient contact	During antimicrobial care	At handover/discharge
Perform hand hygiene and use risk-based PPE.	Confirm indication, allergy and previous exposure.	State medicine, dose, route, time and response.
Assess infection and non-infectious alternatives.	Collect appropriate specimen when feasible.	Communicate pending cultures and review date.
Clean equipment and protect the next patient.	Use guideline-based drug, dose, route and duration.	Explain adherence, adverse effects and return precautions.
Ask about recent admission, surgery and resistant organisms.	Monitor therapeutic response and toxicity.	Document allergies, cultures and prior resistance.
Prevent cross-transmission and isolate when required.	Stop, narrow, switch or escalate after review.	Report suspected outbreak, ADR or medication error.

22. Clinical scenarios and decision-making

Scenario 1 — Viral upper-respiratory symptoms: An adult has two days of runny nose, cough, normal oxygen saturation and no focal chest findings, but requests antibiotics. Reasoning: assess for danger and alternative diagnoses, explain why antibiotics may not help, provide supportive advice and safety-net instructions, and avoid prescribing solely to satisfy pressure.

Scenario 2 — Septic shock after recent admission: A patient is hypotensive, confused and febrile after a recent hospital stay and broad-spectrum antibiotic course. Reasoning: initiate emergency sepsis care, communicate the healthcare exposure, collect cultures if feasible without delay, use local guidance and senior review, and plan early reassessment for resistant infection and source control.

Scenario 3 — Culture result arrives: The patient is improving on a broad IV combination, but the culture identifies a susceptible pathogen that can be treated with a narrower oral option. Reasoning: communicate the result, review indication and stability, de-escalate or switch route under authorised direction, and document the new plan.

Scenario 4 — Positive wound swab without infection: A chronic wound swab grows bacteria, but the patient has no fever, spreading redness, increased pain or systemic illness. Reasoning: distinguish colonisation from infection; do not treat the laboratory result alone. Focus on wound care, assessment and review.

Scenario 5 — Suspected device infection: A patient with a vascular catheter has fever and rigors during infusion. Reasoning: assess ABCDE, stop/secure the infusion as directed, obtain appropriate cultures, notify the team, inspect the device and do not rely on prolonged antibiotics without evaluating removal or source control.

Scenario 6 — Poor response after oral therapy: A vomiting patient has worsening infection after taking oral medicine at home. Reasoning: assess absorption, adherence, dose and diagnosis; stabilise the patient and seek an authorised route and revised plan rather than assuming resistance or repeating an unsafe oral dose.

Scenario 7 — Household transmission: Two family members develop diarrhoea after unsafe water exposure; one has received antibiotics without testing. Reasoning: assess severity and dehydration, use infection prevention, consider public-health notification, obtain tests when indicated and avoid routine antibiotics without a clear indication.

Scenario 8 — Possible AMR outbreak: Several patients in one ward develop infections with similar resistance patterns. Reasoning: notify IPC and clinical leadership, reinforce isolation and cleaning, preserve specimens and records, review antimicrobial use and cooperate with surveillance and outbreak investigation.

23. Common misconceptions about AMR

Misconception	Correct understanding
“AMR means the patient is immune to antibiotics.”	The microorganism is resistant; the patient’s immune status and drug exposure also affect outcome.
“A stronger antibiotic is always better.”	The best medicine is the effective, appropriate, safest and narrowest option for the diagnosed infection.
“Stopping when better always creates resistance.”	Duration should follow the diagnosis and guideline; patients should not change a course without authorised advice.
“A positive culture always means treatment is needed.”	Colonisation and contamination must be distinguished from infection.
“Broad-spectrum antibiotics prevent deterioration in every fever.”	Unnecessary broad therapy causes harm and may delay correct diagnosis.
“Resistance is only a laboratory problem.”	Prescribing, administration, IPC, WASH, vaccination, agriculture and public behaviour all contribute.
“If the first antibiotic fails, simply add another.”	Reassess diagnosis, dose, route, adherence, source control, culture and local resistance.
“AMR is only found in big hospitals.”	Resistant organisms circulate in communities, clinics, hospitals, farms, food and the environment.

24. Examination and revision questions

Define antimicrobial resistance and explain why the microorganism, not the patient, is described as resistant.
Differentiate antibiotics, antivirals, antifungals, antiparasitics, antiseptics and disinfectants.
Explain intrinsic versus acquired resistance.
Describe mutation and selection pressure.
Explain conjugation, transformation and transduction.
List five mechanisms by which microorganisms resist antimicrobials.
What is the difference between colonisation, infection and contamination?
List patient, prescriber, facility, community, animal and environmental drivers of AMR.
Explain how poor infection prevention increases AMR.
What clinical features should raise suspicion of resistant infection?
Why must treatment failure not automatically be labelled resistance?
Define antimicrobial stewardship.
Explain empiric, targeted, prophylactic and suppressive therapy.
What is de-escalation and when may it be appropriate?
Why is diagnostic stewardship important?
List information that should be communicated during AMR-related handover.
What is the role of an antibiogram?
Describe the emergency approach to suspected sepsis in a patient at risk of AMR.
Explain the One Health approach to AMR.
List five actions an EMT can take to reduce antimicrobial resistance.

25. Key takeaways

AMR occurs when microorganisms no longer respond to antimicrobial medicines, increasing the risk of treatment failure, spread and death.
Resistance develops through mutation, selection pressure and transfer of genetic material.
Unnecessary exposure, poor adherence, incorrect dosing, weak diagnostics, poor-quality products and weak IPC all drive AMR.
Emergency care must balance immediate treatment of severe infection with cultures, stewardship, review and source control.
Every antimicrobial decision needs the right indication, drug, dose, route, timing, duration, monitoring and review.
Strong hand hygiene, isolation, cleaning, vaccination, safe water and device care prevent infections and reduce antibiotic use.
Uganda’s AMR response requires One Health coordination, surveillance, laboratory quality, stewardship and public participation.
EMTs are part of the AMR solution through accurate assessment, safe transport, medication history, specimen communication, IPC and patient education.

References and further study

Clinical note: This is an educational revision resource for emergency medical-care students. It does not replace current Ugandan treatment guidelines, laboratory advice, antimicrobial protocols, prescriptions, infection-control policies or specialist review. In a deteriorating patient, stabilise ABCDE and seek urgent senior clinical help while applying antimicrobial and infection-prevention principles.