Publication:

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

Antibiotics are central to reducing infection related mortality. However, misuse has fueled a global antimicrobial resistance (AMR) crisis with the greatest impact in low- and middle-income countries (LMICs), where healthcare systems are often under-resourced. The World Health Organization (WHO) and International Network for Rational Use of Drugs (INRUD) indicators, along with the WHO Access, Watch, and Reserve (AWaRe) classification, provide benchmarks for antibiotic use. This scoping review aimed at examining antibiotic prescription patterns as well as identifying barriers to appropriate prescribing in LMICs. A scoping review was conducted following PRISMA-ScR guidelines. PubMed and Scopus were searched for English language studies published between 2015 and July 2025. Eligible studies reported on prescription patterns using WHO/INRUD indicators, the WHO AWaRe classification, or barriers to appropriate antibiotic prescription. Data were charted and synthesized using descriptive statistics and content analysis. Forty-four (44) studies from twenty (20) LMICs were included in the scoping review. Antibiotic prescribing rates often exceeded the WHO optimal range of 20–26.8%, reaching as high as 94.9% in Sierra Leone. In 78.6% (11/14) of the studies reporting AWaRe classification, the WHO target of ≥60% prescription of access antibiotics was not met, while watch category antibiotics accounted for disproportionately high prescribing levels (>70%) in some countries. The key barriers to appropriate prescription identified in this review included poor prescriber knowledge and attitude, and inadequate access to diagnostics, treatment guidelines, and antibiotics. Antibiotic prescribing in LMICs is frequently suboptimal, with excessive reliance on broad-spectrum antibiotics from the watch category as a result of widespread system and prescriber-level barriers that influence appropriate antibiotic prescription. Strengthening diagnostics while ensuring reliable access to antibiotics, increasing access to updated guidelines, and engaging prescribers and communities through tailored stewardship programs are essential to improve antibiotic prescriptions in LMICs.