A scoping review of antimicrobial stewardship programmes in tertiary hospitals across low- and middle-income countries

Abstract

Antimicrobial resistance (AMR) represents a growing global public health threat, with low- and middle-income countries (LMICs) disproportionately affected due to high infectious disease burdens, constrained healthcare resources, and challenges in antimicrobial governance. Antimicrobial stewardship programmes (ASPs) have been widely promoted as a key strategy for optimizing antimicrobial use and mitigating the emergence and spread of resistance. However, evidence regarding the implementation, effectiveness, barriers, and facilitators of ASPs in tertiary hospitals across LMICs remains fragmented. To map and synthesise the existing evidence on antimicrobial stewardship programmes in tertiary hospitals across low- and middle-income countries, with emphasis on implementation models, programme outcomes, barriers, facilitators, and evidence gaps. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guideline. A comprehensive search was conducted in PubMed/MEDLINE, Scopus, Web of Science, Embase, and CINAHL from database inception to May 2026. Studies were eligible if they were peer-reviewed primary studies conducted in tertiary hospitals within LMICs and reported antimicrobial stewardship programme implementation, interventions, outcomes, barriers, or facilitators. Study selection, data extraction, and thematic synthesis were conducted using predefined eligibility criteria based on the Population–Concept–Context framework. A total of 4840 records were identified, of which 12 studies met the final inclusion criteria. Three major themes emerged from the synthesis: (1) status and models of ASP implementation (2), reported changes in antimicrobial use and prescribing practices, and (3) barriers, facilitators, and strategies for sustainable stewardship programmes. The findings revealed substantial variability in stewardship implementation across LMIC tertiary hospitals. Educational interventions, prescribing audits, antimicrobial guidelines, and multidisciplinary stewardship teams were commonly reported stewardship approaches. Included studies reported improvements in selected antimicrobial prescribing practices following or alongside stewardship activities, although implementation and outcomes varied considerably across settings. Key barriers included inadequate diagnostic capacity, workforce shortages, limited stewardship training, weak governance structures, poor surveillance systems, and financial constraints. Facilitators included leadership support, multidisciplinary collaboration, stewardship champions, institutional commitment, and context-specific implementation strategies. Antimicrobial stewardship programmes may improve antimicrobial use and prescribing practices in LMIC tertiary hospitals, although the available evidence is heterogeneous and implementation remains strongly influenced by health-system and institutional factors. Sustainable stewardship requires strengthening governance structures, workforce capacity, diagnostic infrastructure, and organisational commitment while adapting stewardship models to local healthcare contexts. Not applicable.