Digital Infrastructure for Antimicrobial Susceptibility Testing and Surveillance: A CLSI and EUCAST-Based Model for Resource-Limited Settings.

Background: Antimicrobial resistance (AMR) poses a significant global health threat, requiring effective antimicrobial susceptibility testing (AST) and surveillance systems. At the University Teaching Hospital of Butare (CHUB) in Rwanda, a baseline Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) identified critical gaps in the Laboratory Information System (LIS), including low capture rates for culture observation (60%) and AST data (25%), no standardization of AST panels (0%), and limited cumulative antibiogram generation (17%). Existing AMR surveillance platforms, such as the Information System for Monitoring Antimicrobial Resistance by the World Health Organization (WHO) Collaborating Center for Surveillance of Resistance to Antimicrobial Agents (WHONET), and the District Health Information System, operate as standalone systems separate from clinical workflows, which limits their real-time clinical utility. Objective: This study aimed to develop an enhanced, web-based LIS integrated within routine clinical care to improve AST reliability, enable real-time AMR surveillance at CHUB, and provide a scalable model for subnational and national surveillance networks in resource-limited settings, supporting antimicrobial stewardship. Methods: We developed an enhanced LIS using the OpenClinic GA, the current open-source hospital information system at CHUB, integrating Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines, and leveraging metadata from the AMR for R package, WHONET resources, and EUCAST Expert Rules. An agile development approach was used, incorporating a custom database schema, Java-based application programming interfaces (APIs), and web-based user interfaces. The system was designed to support minimum inhibitory concentration (MIC) and disk diffusion (DD) methods, automate result interpretation with color-coded outputs, WHO Access, Watch, Reserve (AWaRe)-based cascade reporting, and enable data export to WHONET for global surveillance. Results: The enhanced LIS improved AST data capture and standardization, providing reliable, automated result interpretation and real-time AMR surveillance capabilities. The system's web-based architecture enables scalability through centralized deployment, allowing multiple facilities simultaneous access. Unlike standalone surveillance tools, the enhanced LIS integrates AST within electronic medical records, maintaining clinical information continuity from specimen registration through result reporting. The system supports immediate clinical decision through AWaRe-based cascade reporting, and automated resistance phenotype detection, followed by standardized WHONET-compatible exports for public health surveillance. Conclusions: This scalable, LIS model demonstrates the feasibility of implementing standards-based AMR informatics in resource-limited settings. By embedding surveillance within clinical workflows rather than treating it as a separate downstream activity, the system maximizes data quality and clinical relevance while minimizing staff burden. The centralized web-based architecture provides inherent scalability from facility to national levels, eliminating data fragmentation and ensuring metadata consistency across networks. Long-term sustainability requires continuous user training, designated personnel for metadata maintenance, local IT capacity building, and funding mechanisms beyond donor dependency. This model provides a practical roadmap for national digital stewardship programs, supporting both immediate patient care and long-term public health surveillance goals.