BACKGROUND:Healthcare-associated infections are a globally recognized adverse event of healthcare delivery due to their associated morbidity, mortality and costs. Infection prevention and control (IPC) measures are predefined sets of activities necessary to ensure safe, high-quality care, not only for patients but also for healthcare workers. However, low- and middle-income countries may have difficulties with executing appropriate IPC measures due to less developed healthcare systems. METHODS:A nationwide cross-sectional survey was undertaken to gather information about the current status of IPC among both public and private secondary and tertiary care hospitals across Pakistan, using the World Health Organization Infection Prevention and Control Assessment Framework (IPCAF) between September and October 2025. RESULTS:In total, 108 hospitals from across Pakistan participated in this study, with the majority from the public sector (82.4%) and tertiary care (52.8%). The median IPCAF score was 349.25 [interquartile range (IQR) 183.88-511.86], indicating basic implementation of IPC core components, with secondary and tertiary care hospitals scoring 293.5 (IQR 183-445) and 393.5 (IQR 201-547.5), respectively. The difference in IPCAF scores between secondary and tertiary care settings was significant, indicating better resources and structures in tertiary care hospitals. Whilst median IPCAF scores were higher for private hospitals compared with public hospitals (431 vs 337.5, respectively), the difference was not significant (P=0.116). The majority of surveyed hospitals had basic to intermediate IPC (29.6%), and 27.8% had inadequate IPC. CONCLUSION:There appeared to be only basic implementation of IPC activities among hospitals across Pakistan. This needs to be addressed urgently, alongside training and appropriate finances, to enhance future IPC activities.

Introduction: Antibiotic shortages in public hospitals across Sub-Saharan Africa (SSA) have emerged as a critical public health challenge. Data on antibiotic shortages are well documented in Europe but remain limited in SSA. This pilot study forms part of a larger project aiming to evaluate the scope, causes and potential mitigation strategies and to address antibiotic shortages among public sector hospitals across SSA. Materials and Methods: Descriptive cross-sectional survey among public hospital healthcare professionals across SSA. Descriptive statistics were calculated using Jamovi. Results: Fifteen participants from 3 SSA countries completed the survey. Shortages occurred 1–3 times in 2024 for 80% (12/15) of participants, lasting mostly less than 2 weeks. Shortages included amoxicillin/clavulanic acid, cefotaxime, piperacillin/tazobactam, linezolid and colistin, covering Access, Watch and Reserve groups. Main causes for shortages were increasing demand (53.8%; 7/15), financial constraints (38.5%; 5/15) and supply-chain problems (38.5%; 5/5). Two-thirds of hospitals had essential antibiotic lists, 53.3% (8/15) used electronic inventory systems and 66.7% (10/15) had therapeutic substitution policies. Two-thirds of respondents reported negative impacts of shortages on patient care (66.7%; 10/15). Pilot testing identified issues with skip logic and question complexity, which are being addressed in the main study to improve clarity and consistency. As a result, enhancing the robustness of future suggestions to alleviate future antibiotic shortages among public hospitals and the implications across SSA. Conclusion: Findings demonstrate the feasibility of the survey approach and highlighted recurrent shortages of essential antibiotics and their impact. A much larger multi-country survey is now being conducted across SSA to inform future strategies.

Background:Benchmarking antibiotic use across different healthcare sectors is crucial to improve use and implement the United Nations General Assembly 70% Access target. Many countries only have available aggregate sales data, which do not have sector-specific usage information. The objective of this study is to estimate the proportion of oral and parenteral antibiotic use across different healthcare sectors. Materials and methods:We used IQVIA MIDAS® Quarterly Sales data and Global Point Prevalence Survey (Global-PPS) hospital healthcare data from eight countries, including Belgium, Canada, China, Netherlands, Philippines, Saudi Arabia, Singapore and the UK, in 2019. Our analysis focused on Access and Watch antibiotics. In the main analysis, we assumed that all parenteral antibiotics were used exclusively in hospital healthcare settings, an assumption we then relaxed through sensitivity analyses. The observed ratios of oral-to-parenteral antibiotics in the patient-level Global-PPS data were calculated, by dividing the volume of oral antibiotic use by that of parenteral antibiotic use, and then this calculated ratio was multiplied by the IQVIA MIDAS sales data to estimate oral antibiotic use outside of the hospital healthcare sector. Results:The ratios of oral-to-parenteral use among hospital healthcare sectors in the Global-PPS data ranged between 0.05 [95% credible interval (CrI): 0.03-0.09] and 1.01 (95%CrI: 0.56-1.80) in the main analysis. We estimated that overall, <7% of national oral antibiotics were used by hospital healthcare sectors, assuming exclusive parenteral use in hospital healthcare settings in the main analysis, and <9% when assuming 90% of parenteral use was hospital healthcare in the sensitivity analyses. Conclusion:Our results indicate that where patient-level data are unavailable, alternative sources, such as antibiotic procurement and supply data including routes of administration, can reasonably estimate sector-specific national use.

Little data is available from the primary healthcare setting in low- and middle-income countries to describe the burden of clinical infections and antibiotic prescribing proportions for those infections. The AWaRe Antibiotic Book provides a framework for assessing antibiotic prescribing in primary healthcare but requires understanding both frequency of clinical infections and their antibiotic prescribing proportions. The Antibiotic Prescribing in Primary Healthcare Point Prevalence Survey (APC-PPS) project is a series of point prevalence surveys conducted at primary healthcare facilities in LMICs to capture the frequency of consultation for different clinical infections and diagnoses and the frequency and type of antibiotic prescribing associated with these infections in primary healthcare facilities. This study aims to assess the feasibility of using a PPS methodology to collect data on clinical presentation and antibiotic prescribing in primary healthcare settings. The data collected are necessary to be able to summarise relative frequencies of presentation of different clinical infections and antibiotic prescribing practices to inform global estimates of antibiotic use and inform the development of surveillance methods and representative sampling frames. Each site will conduct 6-8 point prevalence surveys over the course of 12 months. Completely anonymous data on age, sex, relevant comorbidities, infection symptoms and diagnoses and antibiotic prescription are collected for patients of all ages with acute infection symptoms (up to 14 days of symptoms) who present to the facility on the day of the survey. No identifiable data will be collected from individuals. Data is collected via ODK Collect and stored in a secure ODK Cloud server hosted by City St. George's, University of London. Sites will be active between early 2023- mid 2025, with regular interim data analysis scheduled and final data analysis planned by mid 2026. All required local and national ethical and regulatory approvals will be obtained prior to sites starting.

Background:Antimicrobial resistance (AMR) is a major global health threat that disproportionately affects structurally marginalized groups, including migrants. Yet migrants are largely absent from AMR surveillance systems and response strategies, creating health inequities and undermining global containment efforts. This systematic review examines the evidence base for interventions targeting AMR in migrant populations, with three objectives to summarize existing research; to identify gaps in data collection, intervention design and outcome measurement; and to propose a path towards more equitable, migrant-inclusive AMR responses. Methods:We systematically searched MEDLINE, Embase and PubMed (January 2000-December 2025), following PRISMA guidelines using terms related to migration, AMR and interventions. Tuberculosis studies were excluded and we prioritized interventions addressing WHO Critical and High-Priority pathogens. Results:Of 4039 records screened, only four studies met inclusion criteria, therefore we performed a narrative synthesis. Discussion:Across these studies we identified three persistent gaps: (i) surveillance and monitoring rarely stratified data by migration status, ethnicity or country of origin; (ii) interventions were almost exclusively hospital-based, with little attention to community settings or care pathways; and (iii) outcome measurement was limited, with a narrow focus on microbiological endpoints and few robust clinical or equity-sensitive outcomes. Current evidence on AMR interventions for migrants is scarce, fragmented and insufficient to guide policy. Future work should prioritize high-quality, disaggregated surveillance data, contextually appropriate study designs and community-based care models, enabling rigorous, equity-driven evaluation of interventions.

Background Ensuring appropriate access to essential antibiotics is a critical global public health goal. The UN General Assembly agreed that 70% of global antibiotic use should be WHO Access group. A standard method to estimate optimal antibiotic use based on burden of disease, resistance and local context is needed to inform national policies. Methods Using data from multiple global datasets, we clustered 186 countries, territories and areas (CTAs) into ′peer groups′ based on sociodemographic factors, infection and resistance incidence using a latent class model. Within each cluster, benchmark countries with low antibiotic use and infection mortality were identified. We estimated optimal Total DID given infection burden, Reserve DID based on relevant resistance burdens, Watch DID based on clinical infections requiring Watch antibiotics from the WHO AWaRe Book and Access DID as the residual volume. Findings Globally 43.0 billion DDDs (95%CI:35.4billion–57.7billion) of antibiotics in 2019 were needed in 186 CTAs, of which 76% would optimally be Access (95%CI:70%–82%). CTAs in lower-income clusters required more Watch and Reserve antibiotics than higher income CTAs. Among CTAs with actual use data available, 72% (48/67) of CTAs used more Total and 99% (66/67) used more Watch antibiotics than estimated optimal levels. Implications We present the first estimates of optimal AWaRe antibiotic levels for 186 CTAs. After accounting for country-specific needs, the UNGA 70% Access target is globally appropriate. AWaRe benchmarking enables CTAs to estimate under and overuse of AWaRe antibiotics to inform national policies. Funding The ADILA Project funded by the Wellcome Trust [222051/Z/20/Z]. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The ADILA Project funded by the Wellcome Trust [222051/Z/20/Z]. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The underlying IQVIA MIDAS® antibiotic use dataset is proprietary and cannot be publicly shared. Analysis code, underlying datasets for all other variables and derived estimates will be made available on GitHub with publication.

Background:In Sub-Saharan Africa, over-the-counter antibiotic dispensing and limited resources drive high antimicrobial resistance (AMR), yet data on community-acquired urinary tract infections (UTIs) remain scarce. This review synthesizes available AMR evidence in this population. Methods:We searched MEDLINE, Embase and Global Health (January 2000-April 2026) for studies evaluating AMR in acute community-acquired UTIs across Sub-Saharan Africa. Random-effects meta-analyses evaluated resistance of Escherichia coli and Klebsiella spp. against five commonly prescribed antibiotics. Results:From 3099 screened articles, 42 studies (19 countries) were analysed. Pooled AMR prevalence was high for E. coli and Klebsiella spp., respectively: trimethoprim-sulfamethoxazole [62.2% (95% CI: 51.9%-72.5%) versus 66.4% (95% CI: 46.7%-86.2%)]; amoxicillin-clavulanic acid [48.9% (95% CI: 39.8%-58.0%) versus 47.5% (95% CI: 31.0%-63.2%)]; ceftriaxone [40.8% (95% CI: 19.4%-62.2%) versus 44.6% (95% CI: 28.6%-60.7%)]; ciprofloxacin [32.8% (95% CI: 25.1%-40.4%) versus 35.8% (95% CI: 20.3%-51.4%)] and nitrofurantoin [18.2% (95% CI: 9.2%-27.2%) versus 28.3% (95% CI: 12.1%-44.5%)]. All estimates showed very high heterogeneity (I 2 > 96%), unresolved by subgroup analysis. E. coli resistance to amoxicillin-clavulanic acid increased significantly over time (P = 0.028). Resistance did not differ significantly by pathogen or geographic region. Conclusions:Community-acquired UTIs in Sub-Saharan Africa exhibit high rates of AMR. Addressing this burden requires targeted community antimicrobial stewardship, rapid diagnostic tools to guide empiric therapy and standardized laboratory reporting to enable accurate global surveillance.

Background Ensuring appropriate access to essential antibiotics is a crucial public health goal. The 2024 UN General Assembly agreed that 70% of global antibiotic use should be from the Access group of the WHO Access, Watch, Reserve (AWaRe) system. A standard method to estimate optimal national-level antibiotic use based on burden of disease, resistance, and local context is needed to inform national policies. We aimed to develop and apply a burden-adjusted framework for estimating expected optimal national levels of AWaRe antibiotic use, in total and by AWaRe group. Methods We used data from multiple global sources—including datasets from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021; the Global Research on Antimicrobial Resistance project; and the World Bank—to cluster 186 countries, territories, and areas (CTAs) into four peer groups on the basis of sociodemographic factors, infection burden, and resistance incidence using a latent class model. Within each cluster, we identified benchmark CTAs with low antibiotic use and low infection mortality. For each CTA, we used the infection burden to estimate the optimal total defined daily doses (DDD) per 1000 inhabitants per day (DID) for 2019. We then estimated optimal Reserve DID on the basis of relevant resistance burdens, optimal Watch DID from the number of infections requiring Watch antibiotics as defined in the WHO AWaRe antibiotic book, and optimal Access DID as the remaining volume after accounting for Watch and Reserve antibiotic needs. Where CTA-level data on actual antibiotic use in 2019 were available in the IQVIA MIDAS database, estimated optimal levels were compared with actual levels, in total and by AWaRe group. Findings We estimated that, in 2019, 43·0 billion DDD (95% CI 35·4 billion–57·7 billion) of antibiotics were needed in 186 CTAs, of which 77% (95% CI 71–83) would optimally be from the Access group. CTAs in lower-income clusters required more Watch and Reserve antibiotics than higher-income CTAs: at optimal use levels, 81·7% (80·3–82·9) of global Watch antibiotic need and 80·7% (95% CI 68·5–88·9) of global Reserve antibiotic need would arise from the two lowest-income clusters. Among 67 CTAs with actual antibiotic use data available, 48 (72%) used higher total antibiotic volumes than were estimated optimal. Overuse was most frequent in high-income settings: 33 (87%) of 38 CTAs in the highest-income cluster exceeded the estimated optimal total DID. 66 (99%) of 67 CTAs used more Watch antibiotics than optimal, whereas 36 (54%) used lower volumes of Reserve antibiotics and 28 (42%) used lower volumes of Access antibiotics than were estimated optimal. Interpretation We present estimates for optimal AWaRe antibiotic use for 186 CTAs. After accounting for CTA-specific needs, the UN General Assembly's target of 70% of global antibiotic use being from the Access group seems globally appropriate. Benchmarking the use of AWaRe antibiotics enables estimates of their underuse and overuse in individual CTAs, helping to inform national policies. Funding The Antibiotic Data to Inform Local Action (ADILA) Project, funded by the Wellcome Trust.

Distinguishing enteric (typhoid and paratyphoid) fever from other causes of fever is challenging. The diagnostic accuracy of Typhoid Rapid Diagnostic Tests (RDT) are suboptimal but might improve if combined with a clinical score. We aimed to develop a clinical score, incorporating a point of care C-reactive protein (CRP) and Typhoid RDT, that could be used for febrile patients attending a health facility with limited laboratory capability, to identify those suitable for further investigations such as a blood culture, an empirical antimicrobial choice that covers enteric fever, or to rule out enteric fever as a likely diagnosis. Overall, 1168 Bangladeshi, Cambodian and Nepali children and adults attending hospital with fever were randomly split (80:20) into derivation and validation cohorts. There were 208/1168 (18

Little data is available from the primary healthcare setting in low- and middle-income countries to describe the burden of clinical infections and antibiotic prescribing proportions for those infections. The AWaRe Antibiotic Book provides a framework for assessing antibiotic prescribing in primary healthcare but requires understanding both frequency of clinical infections and their antibiotic prescribing proportions. The Antibiotic Prescribing in Primary Healthcare Point Prevalence Survey (APC-PPS) project is a series of point prevalence surveys conducted at primary healthcare facilities in LMICs to capture the frequency of consultation for different clinical infections and diagnoses and the frequency and type of antibiotic prescribing associated with these infections in primary healthcare facilities. This study aims to assess the feasibility of using a PPS methodology to collect data on clinical presentation and antibiotic prescribing in primary healthcare settings. The data collected are necessary to be able to summarise relative frequencies of presentation of different clinical infections and antibiotic prescribing practices to inform global estimates of antibiotic use and inform the development of surveillance methods and representative sampling frames. Each site will conduct 6–8 point prevalence surveys over the course of 12 months. Completely anonymous data on age, sex, relevant comorbidities, infection symptoms and diagnoses and antibiotic prescription are collected for patients of all ages with acute infection symptoms (up to 14 days of symptoms) who present to the facility on the day of the survey. No identifiable data will be collected from individuals. Data is collected via ODK Collect and stored in a secure ODK Cloud server hosted by City St. George’s, University of London. Sites will be active between early 2023- mid 2025, with regular interim data analysis scheduled and final data analysis planned by mid 2026. All required local and national ethical and regulatory approvals will be obtained prior to sites starting.

Background: The World Health Organization (WHO) AWaRe (Access/Watch/Reserve) book gives detailed guidance on the optimal use of antibiotics across primary care and hospitals for adults and children with the aim of improving the quality of use. Objectives: To develop universally applicable, model sets of appropriate and feasible quality indicators based on the WHO AWaRe system for primary care, hospital, and general indicators for optimal antibiotic use. Methods: Indicators from a scoping review were revised to focus on clinical infections in the AWaRe book. They were assessed using consensus techniques through two rounds each of the Global Delphi Technique and RAND/UCLA Appropriateness Method, evaluating appropriateness and feasibility at national and global levels respectively. In Round 1 of each method, panellists rated clarity and suggested revisions or new indicator. Round 2 results are reported. Findings: There were 102 quality indicators (Primary Care: 46; Hospital: 39; General: 17) included in Round 2 of the Delphi Technique and 136 indicators (Primary Care: 56; Hospital: 60; General: 20) in Round 2 of the RAND/UCLA method, which are presented as model sets of indicators. From these broad sets, 12 indicators from the Delphi Technique and 31 indicators from the RAND/UCLA method were rated both appropriate and feasible with agreement respectively. Conclusion: These model AWaRe-based, universally applicable quality indicators can be locally adapted to improve the optimal use of antibiotics and inform global and country specific antimicrobial stewardship programs (AMS). ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was done as part of the ADILA project (Wellcome Trust Grant Number 222051/Z/20/Z) and supported by Fleming Fund TACE Asia and Africa which is funded by the Department of Health and Social Care (DHSC)s Fleming Fund using UK aid. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript and supplementary

Background:There are concerns globally with rising rates of antimicrobial resistance (AMR), particularly in low- and middle-income countries (LMICs). AMR is driven by high rates of inappropriate prescribing and dispensing of antibiotics, particularly Watch antibiotics. To develop future interventions, it is important to document current knowledge, attitudes and practices (KAP) among key stakeholder groups in LMICs. Methods:We undertook a narrative review of published papers among four WHO Regions including African and Asian countries. Relevant papers were sourced from 2018 to 2024 and synthesized by key stakeholder group, country, WHO Region, income level and year. The findings were summarized to identify pertinent future activities for all key stakeholder groups. Results:We sourced 459 papers, with a large number coming from Africa (42.7%). An appreciable number dealt with patients' KAP (33.1%), reflecting their influence on the prescribing and dispensing of antibiotics. There was marked consistency of findings among key stakeholder groups across the four WHO Regions, all showing concerns with high rates of prescribing of antibiotics for viral infections despite professed knowledge of antibiotics and AMR. There were similar issues among dispensers. Patients' beliefs regarding the effectiveness of antibiotics for self-limiting infectious diseases were a major challenge, although educational programmes did improve knowledge. The development of the AWaRe (Access, Watch and Reserve) system, including practical prescribing guidance, provides a future opportunity for the standardization of educational inputs. Conclusions:Similar KAP regarding the prescribing and dispensing of antibiotics across LMICs and stakeholder groups presents clear opportunities for standardization of educational input and practical training programmes based on the AWaRe system.

Benchmarking antibiotic use across different healthcare sectors is crucial to improve use and implement the UNGA 70% Access target. Many countries only have available aggregate sales data, which do not have sector-specific usage information. The objective of this study is to estimate the proportion of oral antibiotic use across different healthcare sectors. We used IQVIA MIDAS ® Quarterly Sales data and Global Point Prevalence Survey (Global-PPS) inpatient data from eight countries, including Belgium, Canada, China, Netherlands, Philippines, Saudi Arabia, Singapore, and United Kingdom, in 2019. Our analysis focused on Access and Watch antibiotics. In the main analysis, we assumed that all parenteral antibiotics were used exclusively in inpatient settings, an assumption we then relaxed through sensitivity analyses. The observed ratios of oral-to-parenteral antibiotics in the patient-level Global-PPS data were calculated, by dividing the volume of oral antibiotic use by that of parenteral antibiotic use, and then this calculated ratio was multiplied to the IQVIA MIDAS sales data to estimate oral antibiotic use outside of the inpatient sector. The ratios of oral-to-parenteral use among inpatients in the Global-PPS data ranged between 0.05 (95%Credible Interval [CrI]: 0.03-0.09) and 1.01 (95%CrI: 0.56-1.80) in the main analysis. We estimated that overall, less than 7% of national oral antibiotics were used by inpatients, assuming exclusive parenteral use in inpatient settings in the main analysis, and less than 9% when assuming 90% of parenteral use was non-inpatient in the sensitivity analyses. Our results suggest that where patient-level data are unavailable, alternative sources, such as antibiotic import data including routes of administration, can reasonably estimate sector-specific national use.

OBJECTIVES:Antimicrobial resistance (AMR) presents significant challenges for the effective treatment of pneumococcal disease (PD), disease prevalence, and vaccine effectiveness caused by S. pneumoniae. We aimed to describe the pattern of AMR among isolates from patients with PD reported in the Hong Kong population from 2012-2021, and to explore the risk factors associated with AMR among patients hospitalized with PD compared to those with susceptible isolates. METHODS:PD-related hospitalizations were identified and grouped into invasive PD (IPD) or non-IPD patients. Electronic health records were collected to calculate the healthcare resource utilization relevant to each IPD/non-IPD patient. We compared the characteristics of patients with IPD/non-IPD caused by non-susceptible isolates (cases) and those without (controls) using a multivariable logistic regression model, looking for risk factors for AMR. RESULTS:The PD incidence trend was stable from 2012 to 2019 with a sudden decrease in 2020, coinciding with the beginning of the COVID-19 pandemic. Overall, 80% of patients had S. pneumoniae non-susceptible to ≥1 antibiotic. The percentage of non-susceptibility found to tetracyclines, macrolides, penicillin, and fluoroquinolones, were 85%, 79%, 23% and 2%, respectively. Overall, 46% of the patients with serotyping results were serotype 3. Significantly increased odds of AMR infection were found among the non-IPD patients aged 2-17 years when compared to older patients (18-64 years). CONCLUSIONS:Measures to reduce non-susceptible S. pneumoniae infections should focus on children and adolescents of school age. Despite the introduction of PCV13 in 2011, serotype 3 and AMR continued to threaten people in the community. Serotype 3-infected patients accounted for nearly half of the patients with PD with serotyping results.

Urinary tract infections (UTIs) are one of the most common bacterial infections globally and a leading cause for outpatient visits. In Sub-Saharan Africa, widespread over the counter dispensing of antibiotics and limited healthcare resources contribute to high levels of antimicrobial resistance (AMR) in the community. However, data on AMR in community-acquired UTIs remain scarce. This systematic review addresses this knowledge gap by synthesizing the available evidence on AMR in this patient population. We aimed to determine the resistance rates of the most common pathogens causing community-acquired UTIs in Sub-Saharan Africa to the antibiotics most frequently prescribed for their treatment. Additionally, we sought to evaluate whether resistance patterns varied geographically or temporally within the region. A systematic search was conducted for peer-reviewed literature published between 1 January 2000 and 1 November 2024 using Medline, Embase and Global Health databases. The search strategy captured studies evaluating AMR in community-acquired UTIs within the target region. Exclusion criteria included: studies with less than 10 bacterial isolates and those involving patients with comorbidities that predispose them to complicated infections. Studies were screened independently by two reviewers at the title, abstract and full text stages before extracting data onto a standardized spreadsheet. Quality assessment was done using an adapted descriptive tool that considered laboratory methodology and data completeness. Random-effects meta-analysis and forest plots analysed resistance rates of Escherichia coli and Klebsiella spp., the most common pathogens, against five antibiotics most frequently used for treatment. The systematic database search identified 2271 articles for screening; 41 studies from 19 countries across Sub-Saharan Africa met the inclusion criteria. These studies contained antimicrobial susceptibility data on 6245 E. coli and 930 Klebsiella spp. isolates with 10 antibiotic-organism pairs (2 bacterial species and 5 antibiotics) selected for analysis. Among the antibiotics examined, trimethoprim–sulfamethoxazole demonstrated the highest resistance rates with 63.2% (Standard Error [SE]=5.4) of E. coli and 66.4% (SE=10.1) of Klebsiella spp. Nitrofurantoin showed significantly lower resistance rates: 8.2% (SE=4.6) and 28.3% (SE=8.2), respectively. E. coli resistance to ceftriaxone (30.8%, SE=5.8) and ciprofloxacin (32.8%, SE=3.9) was also significantly lower than trimethoprim/sulfamethoxazole resistance. Heterogeneity was consistently very high (>95%) across all antibiotic-organism pairs, seemingly driven by different UTI definitions and laboratory methodologies. Subgroup analyses revealed that geography (country or region) did not account for this variability. When stratified by time (5 year groups), only E. coli resistance to amoxicillin/clavulanic acid showed a significant reduction in heterogeneity (Q test for moderators, P=0.013). In Sub-Saharan Africa, data on AMR in community-acquired UTIs are severely limited and most countries lack eligible studies. Included studies utilized a variety of laboratory definitions for UTI positivity and antimicrobial susceptibility testing guidelines. Nitrofurantoin has the lowest observed resistance rates, in line with the African Standard Treatment Guidelines for UTI management. Given high trimethoprim/sulfamethoxazole resistance rates, its empirical use should be reconsidered. We found no temporal trends in resistance patterns over the 24 years or a significant geographical variation within Sub-Saharan Africa.

Staphylococcus aureus causes a wide variety of infections, ranging from simple skin and soft tissue infections to life-threatening bloodstream infections. S. aureus was associated with over 1.1 million deaths globally in 2019.1 In the United Kingdom S. aureus is the second most frequent cause of bloodstream infections with around 5000 deaths per year. Moreover, MRSA is listed a high-priority pathogen by the WHO, and when isolated from blood cultures is in the mandatory national surveillance programme. To investigate the longitudinal trends in S. aureus bloodstream infections, resistance patterns and antibiotic prescribing at St George’s NHS Trust over a 10 year period. We conducted a retrospective analysis of laboratory and medical records from St George’s NHS Trust. All positive S. aureus blood cultures collected between January 2014 and May 2024 were included together with the susceptibility results for all antibiotics tested. Available pharmacy prescribing records were also reviewed (April 2017–May 2024) to evaluate antibiotic use by class, age group and year. We identified 917 patients (941 cases) with a mean annual incidence of 85.6 cases (95% CI: 80.1–91.0). The majority were due to MSSA (93.7%) with a significant upward trend over the ten years (P=0.002), MRSA remained stable (5.36 cases/year; 95% CI: 2.77–7.95). The prevalence of fluoroquinolone-resistant strains increased most markedly, particularly for levofloxacin and moxifloxacin (P=0.001 and P=0.01) which rose from 0 to 12.50% and 12.58% respectively, particularly in MSSA isolates. A total of 16 134 antibiotic prescriptions were recorded for 537 patients over the 7 year period. Antibiotic prescribing largely aligned with NHS treatment guidelines, with penicillins prescribed predominantly (48.8%), and the most common of this group was flucloxacillin (37.6%). Regression analysis showed increasing use of penicillins, cephalosporins, carbapenems, tetracyclines, linezolid and ciprofloxacin, and a decreasing use of macrolides and teicoplanin over the timespan. MSSA incidence accounted for most S. aureus bloodstream infections in St George’s NHS hospital over the 10 year period and increased significantly over time, MRSA incidence remained stable. Fluoroquinolone resistance rose markedly, particularly for levofloxacin and moxifloxacin among MSSA isolates. Antibiotic prescribing patterns were broadly consistent with NHS guidelines, with increasing use of penicillins, linezolid and other classes, and declining use of macrolides and teicoplanin over the 10 years.

High-quality microbiology data are critical to inform antimicrobial stewardship, resistance surveillance and clinical decision-making. Yet, the utility of many existing microbiology datasets is impeded by considerable variability in clinical sampling and laboratory practices along with demonstrable inconsistencies in antimicrobial susceptibility testing (AST) data and reporting. This study, conducted within the Comprehensive Understanding of Disease and AI Research (CURE) project in collaboration with City St George’s and the University of Leeds, aims to verify and validate a rule-based system developed by SmartBiotic® to evaluate microbiological data prior to analysis. The data quality assessment was conducted according to the guidelines of EUCAST and CLSI, which describe the criteria for resistance and susceptibility of bacterial phenotypes. We developed a rule-based system incorporating these standardized criteria which we validated using existing laboratory data. Three performance indicators were established: (i) the number of conflicts between our rules based application and real-world data, identifying potential laboratory errors, (ii) the percentage of laboratory tests performed for which the rule had already provided the answer, and (iii) the percentage of inferred results that could be generated by the system to evaluate dataset enrichment capabilities. A total of 539 bacteriological rules were identified from EUCAST and CLSI. From 1138 antibiograms, 17 051 antibiotic susceptibility tests were produced in the laboratory which were analysed in our system. Of these, 84 results (5‰) were found to be in conflict with the rules, while 231 redundancies with the rules were detected. In addition, 11 264 additional results could be inferred using the available data together with the rules, this led to a 66% expansion of the database. The rule-based algorithm according to EUCAST and CLSI guidelines successfully integrates the concerted effort to enhance the reporting and analysis of available human clinical microbiology data; this set of rules can be used to harmonize global data standards. The system demonstrates a practical utility for identifying data inconsistencies and enriching datasets through validated inference mechanisms. Expert validation by clinical microbiologists and infectious disease specialist consultations are planned to further refine system applicability.

INTRODUCTION:Antimicrobial resistance (AMR) poses a significant threat, particularly in low- and middle-income countries (LMICs), exacerbated by inappropriate antibiotic use, access to quality antibiotics and weak antimicrobial stewardship (AMS). There is a need to review current evidence on antibiotic use, access, and AMR, in primary care across key countries. AREAS COVERED:This narrative review analyzes publications from 2018 to 2024 regarding access, availability, and use of appropriate antibiotics. EXPERT OPINION:There were very few studies focussing on a lack of access to antibiotics in primary care. However, there was considerable evidence of high rates of inappropriate antibiotic use, including Watch antibiotics, typically for minor infections, across studied countries exacerbated by patient demand. The high costs of antibiotics in a number of LMICs impact on their use, resulting in short courses and sharing of antibiotics. This can contribute to AMR alongside the use of substandard and falsified antibiotics. Overall, limited implementation of national action plans, insufficient resources, and knowledge gaps affects sustainable development goals to provide routine access to safe, effective, and appropriate antibiotics. CONCLUSIONS:There is a clear need to focus health policy on the optimal use of essential AWaRe antibiotics in primary care settings to reduce AMR in LMICs.

Antimicrobial Resistance (AMR) is a global public health crisis, with a range of potential interventions that must be optimised to achieve global targets. Evaluating the interventions requires accurate estimates of how the AMR burden of infection will change over time, especially given likely demographic shifts. This study aimed to provide an estimate of future burden in Europe, investigating resistance variation by age and sex and the impact of interventions to achieve the scale of proposed UN political declaration targets. Using data from 12,807,473 bloodstream infection (BSI) susceptibility tests from routine surveillance in Europe, we estimate age- and sex-specific rates of change in BSI incidence for 8 bacteria over 2015- 2019. This was used to project incidence rates by age and sex for 2022-2050 and, with demographic projections, to generate estimates of BSI burden (2022–2050). Bayesian hierarchical models were fitted across 38 bacteria-antibiotic combinations to the 2010-2019 resistance proportion of BSI at the country-level with and without age/sex disaggregation. Inputting the incidence estimates into the “agesex” and “base” model respectively, we sampled 1,000 model estimates of resistant BSI burden by age, sex and country to determine the importance of age and sex disaggregation. We explored Intervention scenarios consisting of a 1, 5, or 20 per 100,000 per year reduction in infection incidence rate of change or an age-targeted 5 per 100,000 per year reduction in those aged 65 years and older. Overall, in Europe, BSI incidence rates are predicted to increase more in men than women across 7 of the 8 bacteria ( P. aeruginosa was the exception) and are projected to increase more dramatically in older age groups (74+ years) but stabilise or even decline in younger age groups. We project huge country-level variation in resistance burden to 2050, with opposing trends visible in different countries for the same bacteria-antibiotic combinations (e.g. aminoglycoside resistant Acinetobacter spp. ranged from a relative difference of 0.34 to 15.38 by 2030). Not accounting for age and sex results in differing resistance burden projections, with 47% of bacteria- antibiotic combinations resulting in an overall under-estimate of resistant BSIs by 2030. Not including age/sex resistance patterns underestimates male cases for 76% (29/38) of the combinations compared to 11% (4/38) for women. We also often see strong age-based associations in resistant BSIs projections with bigger differences at older ages. Achieving a 10% reduction in resistant BSI incidence by 2030 (equivalent to the UN 10% mortality target) was possible only for 57% (26/38) of bacteria-antibiotic combinations even with large reductions in BSI incidence rate of change of -20 per 100,000 per year. In some cases despite achieving a 10% reduction, the resistant BSI burden bounces back to above previous levels by 2050. Including country-specific age- and sex-specific resistance levels alongside projected demographic shifts has a large impact on resistant BSI infection burden projections in Europe even to 2030. Reducing this AMR infection burden by 10% will require substantial reductions in infection incidence rates.

Background: Antibiotic shortages in public hospitals across sub-Saharan Africa represent a growing public health crisis, increasing antimicrobial resistance (AMR). While European countries have conducted several surveys on medicine shortages, similar data are scarce in sub-Saharan Africa. Ensuring the availability of critical antibiotics among hospitals across Africa is essential for effective treatment of infectious diseases and for implementing targeted Antimicrobial Stewardship Programmes (ASPs) to reduce AMR. Objective: To evaluate the scope, causes and potential solutions regarding antibiotic shortages in public sector hospitals across sub-Saharan Africa. Subsequently, use the findings to make recommendations for future strategies, including ASPs. Methods: A cross-sectional descriptive survey will be undertaken among hospital pharmacists, nurses, physicians and other healthcare professionals across sub-Saharan Africa. An electronic questionnaire, based on the European Association of Hospital Pharmacists (EAHP) model and available in English, French and Portuguese, will gather data on the frequency, types, causes and proposed solutions to antibiotic shortages in hospitals. The survey will run for two months, leveraging existing professional networks to enhance participation. Open-ended responses will be summarised in in Excel. Descriptive statistics will include frequencies, percentages, means and standard deviations, and will be calculated using STATA® to summarise both categorical and continuous variables. Discussion and Conclusion: This study will provide comprehensive data on the prevalence and drivers of antibiotic shortages in public hospitals in this important region. The findings will inform national and regional health policies, strengthen supply chain resilience and support ASP implementation. This will be the first time that such a comprehensive survey will be conducted across sub-Saharan Africa as part of the drive to reduce AMR.