AbstractBackground: Antimicrobial resistance (AMR) surveillance remains limited across the Horn of Africa because of constrained laboratory infrastructure and fragmented microbiological reporting systems. This study established the first hospital-based cumulative antibiogram in Somaliland using Clinical and Laboratory Standards Institute (CLSI) M39-A4 methodology and WHONET software to provide a baseline surveillance model for resource-limited healthcare settings.Methods: A retrospective surveillance study was conducted using microbiology records collected over a 12-month period (January–December 2025) at a tertiary referral hospital in Somaliland. Duplicate isolates were removed according to CLSI M39-A4 recommendations by including only the first isolate per patient per species. Intermediate susceptibility results were categorized as resistant. Subgroup comparisons by specimen source were evaluated using Fisher’s exact test.Results: From 1,787 validated laboratory records, 277 unique bacterial isolates were analyzed. Escherichia coli was the predominant pathogen (50.9%, n=141), followed by Staphylococcus aureus (33.6%, n=93). Nitrofurantoin demonstrated the highest susceptibility rate (78.5%), followed by gentamicin (60.4%). Low susceptibility rates were observed for ampicillin (7.3%), ciprofloxacin (19.0%), and meropenem (30.5%). Wound/pus E. coli isolates demonstrated lower meropenem susceptibility than urinary isolates (13.3% vs. 35.4%), although subgroup differences were not statistically significant (p>0.05).Conclusion: This study establishes the first standardized cumulative antibiogram generated in Somaliland using CLSI M39-A4 and WHONET methodology. The findings highlight the need to strengthen antimicrobial stewardship, microbiological diagnostics, and structured AMR surveillance systems in resource-limited healthcare settings.