Antimicrobial stewardship interventions currently implemented at primary healthcare settings across low- and lower-middle-income countries (LLMICs)

Clinical Snapshot

Key Findings

• P Value: Not reported at the review level.

• Effect Size: Not quantified; no pooled effect size reported. Findings are directional only (all studies showed improvement).

• Primary Outcome: All 13 included studies reported improvement in antimicrobial stewardship outcomes. The most common AMSP focus was optimising antibiotic use (n=8 studies), followed by improving diagnostics and monitoring (n=3), and education and training (n=2).

• Nnt Or Sensitivity: Not calculable from available data. No NNT, sensitivity/specificity, or hazard ratio reported at the review level. Individual study-level effect estimates are not synthesised.

• Confidence Interval: Not reported; no meta-analysis performed.

Clinical Application

Feasibility is contextually variable. The review identifies lack of resources as the most commonly reported barrier (n=9 studies), suggesting that even evidence-based AMSPs face significant implementation challenges in LLMICs. Facilitators — including AMS knowledge, educational resources, adequate funding, and transparent procedures — are actionable targets for health system strengthening. Scaling beyond pilot programmes to national policy remains the critical unmet challenge. While Australia is a high-income country and outside the direct scope of this review, the findings carry indirect relevance. Australia's National Antimicrobial Resistance Strategy 2020–2025 and the RACGP's position on antibiotic stewardship in general practice share conceptual alignment with the AMSP domains identified. Australian global health practitioners, aid agencies (e.g., DFAT), and researchers working in the Indo-Pacific region — including PNG, Timor-Leste, and Pacific Island nations classified as LLMICs — may find this review useful for programme design. The TGA's ongoing AMR surveillance work and Australia's commitments under the WHO Global Action Plan on AMR also contextualise this evidence. PBS-listed antibiotic prescribing patterns in Australia differ substantially from LLMIC contexts, but lessons on education-based stewardship interventions are transferable. Primary healthcare workers, policymakers, and health system planners in low- and lower-middle-income countries seeking to implement or scale antimicrobial stewardship programs. Most directly applicable to settings with limited laboratory infrastructure, high rates of informal antibiotic dispensing, and nascent national AMR action plans.

Abstract

BACKGROUND: Antimicrobial resistance (AMR) is a top global public health and development threat. Antimicrobial stewardship programs (AMSPs) are one of the most cost-effective interventions to optimize the use of antimicrobials. This study reviews AMSPs that have been implemented in low- and lower middle-income countries. METHODS: A systematic search was conducted on electronic databases including MEDLINE, PubMed, Embase, OVID, Web of Science and Cochrane Library on 18 July 2024 for published papers from 2014 to 2024 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Relevant published literature was then selected based on the established inclusion/exclusion criteria. Each article was screened by two independent reviewers. Data were extracted and synthesized in the review. RESULTS: Of the 425 articles screened, only 13 were eligible for review and included in this study. Two studies were multinationals. Five studies were randomized controlled trials. Among the three key focuses of AMSPs, most of the interventions focused on optimizing antibiotic use (n=8), followed by improving diagnostics and monitoring (n=3) and education and training (n=2). The most commonly reported barriers to implementing AMSPs was a lack of resources (n=9). Facilitators reported included knowledge of AMS (n=8), availability of educational and training resources (n=8), adequate funding (n=6), accountable and transparent procedures (n=5) and positive communication within healthcare facilities (n=4). CONCLUSIONS: All included studies show improvement in AMS through innovative programs. However, only a few have been adopted nationwide and influence policy formulation in the country. We recommend adoption of effective AMSPs into the national strategic planning and implementation across primary health settings.

References

1. 1.Babatunde, A. O., Ibrahim, A. D., Egbewande, O. M., Olabode, W., Aroyehun, N., Tieosapjaroen, W., Babatunde, Y., & Kpokiri, E. (2026). Antimicrobial stewardship interventions currently implemented at primary healthcare settings across low- and lower-middle-income countries (LLMICs). International Health. Advance online publication. https://doi.org/10.1093/inthealth/ihaf136