Antimicrobial resistance (AMR) is a global threat and is thought to be acute in low and
middle income country (LMIC) settings, including in Kenya, but there is limited unbiased
surveillance that can provide reliable estimates on its burden. Antibiotic use in Kenya may be influenced by marketing, opinion leaders, and patient pressure rather than evidence in absence of microbiology results trusted by clinicians. Current efforts to build capacity for microbiology testing in Kenya are unlikely to result in systematic routine microbiological testing linked to clinical outcomes in the immediate future to inform the burden of AMR and guide empirical choice of antibiotics. The project propose to build on an existing collaborations, the Clinical Information Network (CIN), to pilot microbiology surveillance using a ‘hub-and spoke’ model where selected hospitals are linked to high quality regional microbiology laboratories(KEMRI centres).  During the surveillance, blood culture results will be sent back to hospitals for patient management. The project will produce patient-level microbiology data linked to clinical parameters and outcomes. Results from the pilot hospitals will feed into existing national reporting system existing in Kenya and anonymised microbiological data linked to patient outcomes will be shareable with global initiatives to map and estimate the global burden of AMR. 
Aim is to explore the feasibility, and utility of periodic survey sampling across multiple
public hospitals to inform antibiotic stewardship, and as an interim step to development of
better national or regional laboratories linked to routine surveillance. If feasible this approach is less costly and periodic ‘hub-and-spoke’ surveillance can be used to track AMR trends and to broadly guide empirical antibiotic guidance and is more sustainable than establishing functional microbiological facilities in each hospital (as attempted in high- income countries with various successes) in a LMIC setting. 
Linked to CINAMR , two hospitals with local capacity for microbiology locally will be
supported in an international surveillance initiative referred to as ‘A Clinically Oriented
Antimicrobial Resistance Network (ACORN 2). ACORN 2 seeks to demonstrate
the utility of AMR surveillance linked to clinical outcomes, contribute to local and global data on AMR burden, and explore antibiotic prescriptions practices in routine hospitals.