Antimicrobial resistance (AMR) and healthcare-associated infections (HAIs) such as catheter-related bloodstream infections (CRBSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs), and surgical site infections represent major healthcare challenges globally, with the burden being disproportionately higher in low and middle-income countries (LMICs). ^1–3 These lead to prolonged hospital lengths of stay (LOS), adversely impact patient outcomes, and inflate healthcare bills. ³ Inappropriate use of antibiotics leads to adverse events associated with antibiotics, higher healthcare costs, emergence of multidrug-resistant organisms, and infections such as Clostridioides difficile. ^{Reference Dadgostar4,Reference Mullish and Williams5} Programs designed to target infection prevention and control (IPC) and antimicrobial stewardship (AS) are inter-dependent and share several similarities including process and outcome metrics and resources. ^{Reference Abbas and Stevens6} Incorporation of these programs at healthcare facilities can reduce HAIs, help combat AMR, and improve health outcomes. ^{Reference Abbas and Stevens6}

Reporting of AMR and HAI data is mandatory in many developed countries. ^{Reference Babu Rajendran, Mutters and Marasca7} In response to the 2017 WHO report on the global priority list of antibiotic-resistant bacteria, 21 of 32 countries in the European Union and European Free Trade Association member states implemented mandatory surveys for multidrug-resistant organisms, and 15 provided structural framework for surveillance. ^{Reference Babu Rajendran, Mutters and Marasca7} On the contrary, mechanisms for reporting are lacking in LMICs and high-quality data are sporadic and limited to institutions and hospitals. ^{Reference Abbas and Sultan8} The WHO instituted the global action plan (GAP) to combat AMR in 2015 calling all countries to devise national action plans (NAPs) to combat AMR. Agencies such as the Food and Agriculture Organization of the United Nations and the World Organization for Animal Health have also adopted the GAP. In 2016, the United Nations General Assembly released a declaration acknowledging that humans, animals, plants, and the environment are inter-linked and, a ‘One Health’ approach targeting multiple sectors such as healthcare, industry, agriculture, and livestock, all of which contribute the threat of AMR, must be adopted. ^9–11 Following this, NAPs have been launched in 33 countries in Africa, 14 countries in the Americas, 20 countries in the Eastern Mediterranean, 36 countries in Europe, 11 countries in Southeast Asia, and 22 in the Western Pacific. ¹² These action plans address key issues associated with AMR and outline strategies to counter these by addressing knowledge gaps, enhancing surveillance and research, optimizing the use of antibiotics, reducing HAIs, and mobilizing funding to sustain AS activities. ^12,13 Most LMICs collecting AS data report to the WHO Global AMR Surveillance System (GLASS). ¹² These countries follow individual timelines and reporting intervals. The scope of these programs only allows for a broad-stroke characterization rather than granular assessment as data is collected from a few institutions and with limited geographical representation.

In Europe, HAIs are estimated to prolong hospital LOS by 16 million days, with 37 000 attributable deaths annually. The annual direct healthcare costs are estimated at approximately € 7 billion. ¹⁴ According to a World Health Organization (WHO) report, crude excess mortality attributable to device-associated HAIs in 173 ICUs from 25 countries in Latin America, Asia, Africa, and Europe was estimated at 18.5%, 23.6%, and 29.3% for CAUTI, CRBSI, and VAP, respectively with attributable excess hospital LOS between 5 and 29.5 days. ¹⁴ Another study estimating the global burden of AMR through statistical modeling reported that 4·95 million deaths were associated with bacterial AMR, with 1·27 million (95% uncertainty intervals 0·911–1·71) deaths attributable to bacterial AMR in 2019, including 0.86 million deaths in Africa. ¹⁵ This underscores the importance of robust measures in LMICs to ensure reliable surveillance and timely implementation of necessary measures to improve health outcomes.

The challenges of implementing antimicrobial stewardship programs (ASPs) in resource-constrained settings

Lack of a structural framework and funding for AS activities

A total of 136 countries have launched NAPs to combat AMR globally. However, successful implementation of ASPs is limited by several factors. ^12,16 According to the WHO Global Database for Tracking AMR Country Self-Assessment Survey 2023, multi-sectoral coordination mechanisms on AMR exist in most LMICs. However, functional working groups, funding for surveillance activities, and accountability are lacking. ¹⁶ This may be attributed to the heavy reliance of LMICs on external funding sources such as the Fleming Fund, the WHO, and the U.S Centers for Disease Prevention and Control (CDC). As most of these are short-term, sustainability remains a key challenge. ^{Reference Iskandar, Molinier and Hallit17} Moreover, while the gravity of AMR is acknowledged at the government level, the lack of a formalized reporting and surveillance mechanism, lack of consensus guidelines, and failure to mandate AS activities prevent the effective downstream dissemination of information and implementation of ASPs at healthcare facilities. ^12,16

Shortage of qualified professionals and limited access to resources such as diagnostics and information technology

AS activities are limited by a shortage of trained personnel, including pharmacists and physicians to lead AS initiatives at healthcare facilities. ^{Reference Sengupta, Barman and Lo18,Reference Vijay, Ramasubramanian, Bansal, Ohri and Walia19} Most hospitals lack diagnostic facilities and advanced testing such as rapid molecular diagnostics to support AS activities are largely unavailable. ¹¹ Injudicious prescription of antibiotics is rampant, with a high proportion of antibiotics prescribed empirically and without a clear indication. ¹¹ A handful of hospitals with trained healthcare professionals and availability of resources such as pharmacy and microbiology support, access to information technology, and human resource provisions, may support institutional AS initiatives but the scope of these activities remains very limited (Table 1). Consequently, without granular data on AMR trends, existent policies to combat AMR remain myopic and are unable to identify and address critical gaps.

Table 1. Challenges in implementing infection control and antimicrobial stewardship programs in resource-constrained settings

Note. IPC, infection prevention and control; AS, antimicrobial stewardship; PPE, personal protective equipment; IT, information technology.

Self-medication and access to antibiotics over-the-counter

The culture of self-medication and unhindered access to antibiotics over-the-counter fuels AMR. ^{Reference Aslam, Zin and Jamshed20} A cross-sectional study from Pakistan assessing the sociodemographic factors associated with antibiotic self-medication revealed that approximately 70% of survey participants had used antibiotics over the past year and 30% without consultation with a healthcare professional. ^{Reference Aslam, Zin and Jamshed20} Similarly, a survey of 5 countries in Africa revealed that antibiotics are among the most frequently prescribed medications, with 90% of individuals with acute illness seeking care and 36% being prescribed antibiotics. About 30% of these patients received antibiotics without prescriptions and 25% received antibiotics from informal dispensers. ²¹ The issue is further aggravated in countries such as Afghanistan where international borders are poorly secured, smuggling is rampant, and access to medications, including antibiotics, is not regulated. ¹³

Compartmentalization of health from agricultural and economic sectors

The healthcare sector is, naturally, the initial focus of AMR prevention efforts. However, the concept of One Health is still in its infancy in most LMICs and healthcare represents the sole focus of AMR prevention activities. The compartmentalization of various sectors and failure to recognize the contribution of pharmaceutical and other chemical industries, livestock businesses and agriculture sectors, and inadequate effluent management in municipal systems further promote AMR. ¹⁰ According to an estimate, about 60% of all human pathogens are zoonotic and the increasing human-animal interaction poses a high risk for acquiring these infections. ^{Reference Ikhimiukor, Odih, Donado-Godoy and Okeke22} Antibiotics can be easily purchased over the counter in LMICs and are used for infection prophylaxis, growth promotion, and as food additives in the agriculture and livestock industries. Additionally, improper waste disposal, poor hygiene and sanitation, overcrowding of animals, and failure to use human protective gear while handling animals are key contributors to the surge of AMR among animals. ^{Reference Ikhimiukor, Odih, Donado-Godoy and Okeke22}