Antibiotic prescription patterns and barriers to rational antibiotic use in low- and middle-income countries: a scoping review

INTRODUCTION

Antibiotics have played a transformative role in modern medicine, drastically reducing mortality from bacterial infections and making previously dangerous procedures significantly safer. However, the misuse and overuse of these drugs have fueled the global crisis of antimicrobial resistance (AMR).^1,2 When a new antibiotic is introduced, it may be highly effective in treating infections caused by susceptible bacteria. However, as time goes on, the bacteria develop resistance strategies in the presence of a selection pressure is present in their environment, as a result of the overuse and misuse of antibiotics.^3,4 This phenomenon of resistance developing in bacterial species over time hampers the initial effectiveness of antibiotics that were once effective in treating a particular infection. This can result in treatment failures, prolonged illnesses, and increased healthcare costs.^1,4 The combined threat of rising resistance and dwindling drug options presents a critical barrier to public health, particularly in low- and middle- income countries (LMICs) with under-resourced healthcare systems.³ In 2019, it was estimated that approximately 4.95 million deaths were associated with bacterial AMR globally, of which around 1.27 million were directly caused by bacterial AMR.⁵ The burden was highest in less developed regions such as Western sub-Saharan Africa, with an estimated 114.8 deaths per 100,000 linked to AMR. In contrast, developed regions like Australia reported the lowest burden of AMR, at approximately 28 deaths per 100,000.⁵ Many studies show a significant over prescription of common antibiotics in developing countries, particularly in primary healthcare centers, despite established guidelines for prescription.^2,6,7 World Health Organization (WHO), in collaboration with the International Network for Rational Use of Drugs (INRUD), developed a series of selected indicators to evaluate drug usage in healthcare settings. The WHO/INRUD established essential prescribing indicators includes, the percentage of consultations where antibiotics are prescribed (optimal range of 20.0% to 26.8%).⁸ WHO further developed the “Access, Watch, and Reserve” (AWaRe) framework which shows the WHO classification of antibiotics, which was introduced as part of the 2017 Model List of Essential Medicines. This AWaRe classification offers guidance on the optimal use of these antibiotics by adhering to the principles of Access, Watch, and Reserve categories of antibiotics.⁹ Access antibiotics has a narrow spectrum of action, are affordability, and generally has a low potential for resistance. For these reasons, access antibiotics are suitable as empirical first or second-line treatment options for common infections such as skin and soft tissue infection (mild cases), lower urinary tract infection, and community-acquired pneumonia. In contrast, watch antibiotics are broader in spectrum and typically more expensive.^9,10 They are recommended mainly for severe infections with a higher likelihood of resistance to access antibiotics, such as upper urinary tract infections, infectious acute diarrhea, and enteric fever.¹⁰ Reserve antibiotics are reserved for the most challenging cases for treating multidrug-resistant infections.^9,10 In addition to the aforementioned categories, there is a fourth group for antibiotics that are not recommended for treatment. This group is made up of fixed-dose combinations of various broad-spectrum antibiotics that are not evidence-based and are not endorsed by high-quality international guidelines, and WHO does not advocate for their use in clinical practice.^9,10 The WHO AWaRe classification serves as a valuable tool for assessing the appropriateness of antibiotic usage. According to WHO, at least 60% of global antibiotic consumption at the national level should come from the access category.^9,10 During a high-level meeting on antimicrobial resistance in September 2024, the United Nations General Assembly (UNGA) adopted a political declaration aiming for at least 70% of human antibiotics used globally to be from the WHO Access group by 2030.¹¹ The vast majority of prevalent infections encountered in primary health care can be managed without the use of antibiotics or with access antibiotics. It is essential to minimize the inappropriate utilization of watch antibiotics to combat antibiotic resistance effectively.¹⁰ However, a significant number of prescribers fail to comply with the AWaRe guidelines, contributing to an increase in the prevalence of antibiotic-resistant microorganisms. The AWaRe guideline emphasizes the optimal utilization of access antibiotics, which continue to be the preferred treatment for the majority of infections. It suggests that nine out of the ten most prevalent infections encountered in primary health care can be effectively managed with either no antibiotics or access antibiotics.^9,10 The escalating rates of antibiotic resistance is becoming increasingly urgent, particularly in LMICs, which face significant obstacles in addressing this issue.^12-14 To effectively address antibiotic resistance, frontline healthcare professionals must navigate the complex task of fulfilling patient needs while adhering to best practices in antibiotic prescription and administration.^12-14 Reviews have been conducted to evaluate the effectiveness of interventions in reducing inappropriate antibiotic prescription, while others have synthesized current literature on antibiotic prescription, but these reviews focused on specific countries, high income countries or a mix of economic settings, making it difficult to understand the specific challenges faced by prescribers in LMICs, which is very important in designing targeted interventions and prescription policies to fight AMR in this highly affected setting.^1,4 In addition, reviews have not adequately explored antibiotic prescription patterns in this setting according to the WHO/INRUD prescribing indicators or the WHO AWaRe classification of antibiotics, which is very important.^8,9 Current literature on antibiotic prescription patterns should be reviewed using the WHO/INRUD prescribing indicators and the AWaRe classification. This will help assess whether these guidelines are being followed in LMICs and inform efforts to improve appropriate antibiotic prescription and combat AMR. In addition, existing evidence on the challenges faced by prescribers in LMICs in appropriately prescribing antibiotics should be examined to guide the design of effective interventions.

Given the likely differences across studies in design, context, and outcomes, a scoping review was undertaken to comprehensively map the available evidence on antibiotic prescribing and associated barriers in LMICs. This scoping review aimed to assess the evidence on antibiotic prescription patterns and barriers to performing appropriate antibiotic prescriptions by prescribers in LMICs.

METHODS

This scoping review was conducted and reported following the review protocol in accordance with the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist.¹⁵ The search strategy was developed to identify relevant studies conducted in LMICs, as defined by the World Bank.¹⁶ The search for records combined free-text terms with Boolean operators and were limited to studies published in English between January 2015 and July 2025. Two distinct search strings were used to search for records that address the review objective and questions. The search string searched for information sources on the barriers to appropriate antibiotic use, and the patterns of antibiotic prescription according to WHO/INRUD core prescription indicators and the WHO AWaRe antibiotic classification. This is shown in Table 1. The PubMed and Scopus were the databases searched for sources of evidence within the scope of this review.

Source of evidence selection and data extraction

The list of resource documents obtained through database search in PubMed and Scopus were exported in the form of CSV files and later imported to Zotero version 7.0.21, where duplicates were removed. The title and abstract of records were screened by two independent reviewers. Records were selected if they reported on antibiotic prescription in health facilities in LMICs. Selected records included those reporting on drug use indicators (WHO/INRUD, WHO AWaRe, or both), and those that assessed barriers to antibiotic prescription. The exclusion criteria included records addressing general pharmaceutical use without reporting on antibiotic use, as well as those that focused on specific syndromes such as respiratory infections and urinary tract infections. Records for which the full-text article could not be obtained were also excluded. In addition, review articles, including systematic reviews, scoping reviews, and narrative reviews, were excluded. After a title and abstract screen was conducted, a full text screen was then performed for detailed assessment of the records to determine if they met the inclusion criteria by two independent reviewers. Disagreements between reviewers were resolved through discussion or with the help of an additional reviewer. Data from the included sources of evidence were charted using a standardized data charting form to capture author information, study title, study objective, key findings and country of origin. Data charting was performed by one reviewer and checked by a second reviewer to ensure consistency and accuracy.

Data analysis and presentation

Qualitative content analysis and descriptive statistics were used to analyze the data, and key findings were presented in a summary table, figures and map. Results were organized according to sections to answer the two key review questions.

RESULTS

Search results and characteristics

Literature search on PubMed identified 390 studies, while a literature searches on Scopus identified 866 studies, giving a total of 1256 studies to be screened. After the identified studies were screened for duplicates, 893 studies were selected for title and abstract screen according to the inclusion criteria. The abstract screen was followed by a full-text screen of 55 articles to get the final 44 studies that were included in this review. Figure 1 provides an overview of the evidence selection process that resulted in the inclusion of 44 evidence sources in the review. Table 2 summarizes the characteristics of the studies included in the review and key findings.

The 44 selected studies that were included in this review came from 20 LMICs. Countries such as Ethiopia and Ghana had the maximum number of studies included in the review, followed by India, Jordan, Nigeria, Tanzania, and Uganda, with 3 studies each. Benin, Cambodia, Kenya, Laos, Nepal, Pakistan, and Zambia had 2 studies each in the review, with other countries such as Bangladesh, Cameroon, Democratic Republic of Congo (DR Congo), Sierraleone, Sudan, and Vietnam having a study in the review. A summary of the origin of studies included in the review is found in Figure 2.

The majority of studies included in this review were published between 2020 and the second quarter of 2025, with at least four publications per year. In contrast, fewer studies (20.4%) were published between 2015 and 2019, with only one study identified in 2015. Figure 3 presents the distribution of studies by year of publication, showing an increase in the number of relevant publications in recent years.

Antibiotic prescription patterns in LMICs

Studies included in the review covered multiple LMICs across Africa, Asia, and the Middle East. These studies included point prevalence surveys, cross-sectional prescribing audits, and antibiotic consumption studies in settings such as outpatient and inpatient departments in primary care and tertiary hospitals. To present findings on antibiotic prescription patterns across this setting, findings were organized according to the WHO/INRUD core prescribing indicator and the WHO AWaRe prescription indicators.

WHO/INRUD core prescribing indicator; proportion of patient encounters with at least an antibiotic prescribed

Across the included studies, the proportion of patient encounters receiving at least one antibiotic varied widely, ranging from 17.7% in Jordan to 94.9% in Sierra Leone. Most studies reported antibiotic prescription rates that exceeded the recommended optimal range of 20–26.8%. Notably high rates were observed in several studies, including 94.8% (reported in three separate studies), 94.9%, 88.0%, 84.1%, 82.9%, 82.1%, 75.25%, 72.8%, and 70.0%.^2,17-23 Moderate rates such as 62.2%, 62%, 60.84%, 59.6%, 59.0%, and 55.2% were also reported.^6,14,24-27 A few studies reported rates that were closer to the WHO threshold, including, 49.0%, 47.8%, 44.7%, 44.5%, 36.71%, 36%, and 32.9%.^28-35 A study from Jordan, however, reported a low antibiotic prescription rate of 17.7%.³⁶ Overall, the pattern from these studies indicates that antibiotic prescribing in many LMIC settings remains considerably higher than the WHO recommended optimal range of 20–26.8%.⁸ To further assess the appropriateness of antibiotic prescription in this setting beyond antibiotic prescription rates per patient encounter, the distribution of antibiotics according to the WHO Access, Watch, and Reserve (AWaRe) classification was also examined.

WHO AWaRe (Access, Watch, and Reserve) distribution

The percentage of antibiotics prescribed from the access group ranged from 25.7% to 74%. In the studies reviewed, the percentage of antibiotics categorized within the access group varied between 25.7% and 59.6% across 11 out of the 14 studies, whereas the other 3 studies, which were from Benin, Ghana, and Ethiopia, indicated proportions of 60% or higher.^{2,7,18-23,25,30,32-34,37,38} In the majority (10/14) of the studies, antibiotics prescribed from the Watch group were notably high, with prescription rates exceeding 40% in most cases.^{7,18,20-22,25,30,32,33,37} Particularly elevated proportions were reported in studies from Zambia (52%), Sudan (71.0%), and Sierra Leone (71.7%) [7,18,22]. The prescription of antibiotics from the reserve group of antibiotics was rare with 13 out of 14 studies reporting prescription rates of less than 1% from the reserve category.

However, a study from Pakistan reported 2.2% of antibiotic prescriptions from the reserve group.²⁰ The prescription of not-recommended antibiotic combinations according to the WHO AWaRe classification was reported in some studies, with prescription rates as high as 20.3% and 25.5% reported in studies from the Democratic Republic of Congo and Tanzania, respectively.^2,21

Barriers to appropriate antibiotic prescription

A total of 20 studies included in this review assessed barriers to appropriate antibiotic prescription. This review identified 11 key themes. The main themes identified includes; prescribers’ knowledge and attitudes, inadequate access to diagnostics, Limited access to guidelines, and inadequate access to antibiotics. All themes identified in this review are shown in Table 3.

Prescribers' knowledge and attitudes were reported to influence appropriate antibiotic prescription. Limited knowledge of prescribers on appropriate antibiotic prescription, and inadequate continuous education programs were reported as factors that affected appropriate antibiotic prescription by prescribers.^{12,13,39,40-42} Antibiotic prescription was also reported to be influenced by prescribers’ perception of resistance to narrow-spectrum antibiotics, resulting in a preference for broad-spectrum antibiotics to ensure it covers all possible infections.^13,31,43-45 Senior colleagues were also reported by junior staff to play a key role in inappropriate antibiotic prescription.^37,43 Other prescriber-related factors, such as poor compliance with treatment guidelines, were reported in Zambia as a barrier to appropriate antibiotic prescriptions in health facilities.¹⁴

Inadequate access to diagnostics was reported among the studies included in the review. Limited access to microbiology laboratory services, long culture results turnaround time, and the absence of sensitivity testing were reported to affect appropriate antibiotic prescription.^{14,19,31,39,43,44,46-48} Across studies, antibiotic prescribing was frequently based on empirical therapy, with limited use of laboratory results to guide treatment decisions.^{12,14,43,44,46,48-50}

Limited access to guidelines was commonly reported. An association between inadequate access to treatment guidelines and appropriate antibiotic prescription at healthcare facilities was reported in a study in Kenya, with poor access to up-to-date guidelines identified as a barrier to appropriate antibiotic prescription. This study carried out in Kenya by Maina et al further showed that patients were about 6 times more likely to be prescribed antibiotics appropriately if prescribers had access to treatment guidelines.⁵¹ The poor access to up-to-date or evidence-based guidelines was reported in a series of studies in LMICs as a barrier to appropriate antibiotic prescription.^{12-14,43,46,52}

Inadequate access to antibiotics was identified as a key barrier to appropriate antibiotic prescription in studies from Ethiopia, Nigeria, Laos, and India. These studies highlighted that poor access to antibiotics restricts prescribers’ ability to follow treatment guidelines and policies, resulting in inappropriate antibiotic prescription through the use of less suitable antibiotic alternatives.^{12,39,46,47,50,53}

Inadequate monitoring and support systems in place for continuous monitoring, supervision, and motivation of prescribers were reported as a major barrier to appropriate antibiotic prescription in LMICs. This was reported in studies from Nigeria, Uganda, and Tanzania.^13,46,54

Financial incentives from pharmaceutical companies were reported as contributing factors that hinder the appropriate prescription of antibiotics in studies from Nigeria, Nepal, and Uganda. These factors were reported to encourage prescribers to favor specific antibiotic brands or broad-spectrum agents, irrespective of clinical indication, for financial gain.^13,46,47

High workload was also reported to affect appropriate antibiotic prescription in studies from India and Ethiopia.^12,50

Out-of-pocket payments by patients were identified as one of the barriers to appropriate antibiotic prescriptions by studies from Ethiopia and Nigeria.^12,46

Patient expectations and demand for antibiotics were reported to influence appropriate antibiotic prescription in Cambodia, Uganda, and Nepal. Additional studies from Ethiopia and Nigeria also reported that out-of-pocket payments by patients influenced prescriber decisions, and prescribers were reported to prescribe antibiotics to satisfy patient expectations.^{12,37,43,46,47}

Poor infection prevention and control (IPC) measures in health facilities were also reported to indirectly drive antibiotic overuse, as prescribers turn to prescribe antibiotics that will cover perceived infection risk, as reported in a study from Cambodia by Om et al.⁴³

Over-the-counter sale of antibiotics in pharmacies was reported as a barrier to appropriate antibiotic prescription by Krishna et al in a study that was carried out in health facilities in India.⁵⁰

R indicates that the barrier was identified in the corresponding study; blank indicates that the barrier was not reported in the corresponding study.

DISCUSSION

This scoping review synthesized evidence from 44 studies across LMICs on antibiotic prescription patterns structured around WHO/INRUD prescribing indicators, and the WHO AWaRe classification, and also assessed barriers to appropriate antibiotic prescription.

Studies in this review showed that the proportion of patient encounters prescribed at least one antibiotic was well above the WHO recommended optimal range of 20-26.8%. These findings are consistent with earlier reviews that reported high antibiotic prescribing rates in similar settings, such as a review of studies from Eastern Africa, which showed that the average antibiotic prescription rate per patient encounter was 57%, surpassing the standard put in place by the WHO.⁵⁵ The WHO AWaRe classification analysis further underscores suboptimal prescribing behaviors. Most studies reported the prescription rate of Access category antibiotics to be below the recommended threshold ≥60% by WHO, with a disproportionate reliance on Watch antibiotics. This trend is concerning, as Watch antibiotics are more prone to resistance development and are intended for more targeted, high-risk situations.¹⁰ The low prescription of reserve antibiotics aligns with their restricted availability and stewardship policies, but the observed prescription of non-recommended antibiotic combinations at high percentages of about 20% in countries like Tanzania and the Democratic Republic of Congo suggests gaps in guideline adherence and regulatory enforcement.^2,21 These patterns in antibiotics used according to the AWaRe classification suggest substantial gaps in appropriate antibiotic prescription. While access antibiotics should constitute at least 60% of total antibiotics prescribed, many studies in health facilities failed to meet this benchmark. This finding is in line with a global point prevalence survey that was carried out in 69 countries, which highlighted the overuse of Watch antibiotics.¹

Our synthesis of evidence on barriers to appropriate antibiotic prescription in healthcare facilities in LMICs identified recurring themes across studies. Prescribers' knowledge and attitudes were identified among the major barriers to appropriate antibiotic prescription in this review. This finding is in line with a review by Davari et al that identified the knowledge and attitude of prescribers as barriers to appropriate antibiotic prescription.⁴ Inadequate access to diagnostics was also identified as one of the main barriers to appropriate antibiotic prescription in this setting. This finding is in line with other reviews, such as that reported by Harun et al as well as findings from the Mapping AMR and AMU Partnership (MAAP) project, where only 1.3% of 50,000 medical laboratories across 14 African countries were engaged in bacteriological testing.^56,57 Poor access to diagnostics, including culture and sensitivity testing are a critical driver for over prescription of Watch antibiotics.⁴⁴ Diagnostics are essential in mitigating inappropriate antibiotic prescription, as they allow healthcare professionals to identify the most suitable treatment for specific conditions, thereby minimizing the overuse of antibiotics, which is a driver of antibiotic resistance.⁵⁷ In LMICs, access to diagnostics is primarily centralized, with the test only being accessed at specialized laboratories with limited access for local healthcare facilities, thereby posing challenges for the healthcare system and the patients it serves.⁵⁷ Another key barrier to appropriate antibiotic prescription identified was inadequate access to treatment guidelines. This is in line with a review on LMICs by Harun et al which identified adequate access to treatment guidelines as a key contributing factor to appropriate antibiotic prescription.⁵⁶ The findings from this review further align with broader antimicrobial stewardship literature, which emphasizes the role of treatment guidelines in appropriate antibiotic prescription.⁹ Additional factors such as poor access to antibiotics was identified as another important barrier to appropriate antibiotic prescription. This finding is consistent with a review by Saleem et al in LMICs, where poor access to antibiotics was identified as a key barrier to appropriate antibiotic prescription.⁵⁸ Limited access to antibiotics reduces prescribers’ ability to adhere to treatment guidelines and contributes to the use of alternative or non-recommended antibiotic options.⁵⁸

Limitations

This review has some limitations. First, although a comprehensive search was conducted, the review was limited to English language studies indexed in Scopus, Pubmed or both. Relevant evidence from unpublished or grey literature, as well as studies published in other databases or languages, may therefore have been missed.

CONCLUSION

This scoping review highlights that inappropriate antibiotic prescribing is widespread in LMICs, with prescription rates often exceeding WHO recommendations and access antibiotic use frequently falling short of global targets. Watch antibiotics prescription dominate many hospital settings, and empiric prescribing remains the norm due to poor access to diagnostics. This scoping review identified consistent and interrelated barriers to appropriate antibiotic prescribing in healthcare facilities across LMICs, with prescriber knowledge and attitudes, inadequate access to diagnostics, limited availability of treatment guidelines, and poor access to antibiotics emerging as key barriers.

These barriers were frequently reported across studies and are supported by evidence from regional and global reviews, highlighting their persistence across diverse LMIC settings. Overall, the findings suggest that inappropriate antibiotic prescribing in LMIC healthcare settings is largely influenced by a combination of prescriber-related and health system factors. These findings highlight the need for integrated antimicrobial stewardship interventions that address both behavioral and structural determinants of antibiotic prescribing practices.

Recommendations

The findings from this review shows that there is an urgent need to implement multifaceted antimicrobial stewardship programs (ASPs) tailored to LMIC realities. Effective strategies should include: strengthening diagnostic capacity through the provision of affordable microbiology services and rapid diagnostics, establishing targeted policies that promote sustainable and equitable access to antimicrobials, developing, updating, and disseminating national and facility-level treatment guidelines and embedding them into clinical decision support systems, addressing behavioral drivers of inappropriate antibiotic prescription via continuous professional education and mentorship programs, developing structured systems to monitor and evaluate antibiotic prescription practices in these settings, and strengthening community engagement initiatives to reduce inappropriate patient demand for antibiotics and improving public awareness of AMR.

ACKNOWLEDGEMENTS

The authors would like to express their sincere gratitude to the Department of Public Health, Faculty of Health Sciences of the University of Bamenda for providing the academic environment and institutional support that contributed to the successful completion of this review. They also acknowledge all the researchers whose published work formed the evidence base for this review and contributed to advancing knowledge on antibiotic prescribing practices in low- and middle-income countries.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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