Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription. A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing without a prescription). However, considerable variation with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients. ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists' activities to reduce inappropriate dispensing. Such activities, alongside educating patients and HCPs, should enhance appropriate dispensing of antibiotics and reduce AMR.

Background: The inappropriate use of antibiotics in hospitals contributes to the development and spread of antimicrobial resistance (AMR). This study evaluated the prevalence of antibiotic use and adherence to the World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification of antibiotics across 16 hospitals in Zambia. Methods: A descriptive, cross-sectional study employing the WHO Point Prevalence Survey (PPS) methodology and WHO AWaRe classification of antibiotics was conducted among inpatients across 16 hospitals in December 2023, Zambia. Data analysis was performed using STATA version 17.0. Results: Of the 1296 inpatients surveyed in the 16 hospitals, 56% were female, and 54% were aged between 16 and 50 years. The overall prevalence of antibiotic use was 70%. Additionally, 52% of the inpatients received Watch group antibiotics, with ceftriaxone being the most prescribed antibiotic. Slightly below half (48%) of the inpatients received Access group antibiotics. Compliance with the local treatment guidelines was 53%. Conclusions: This study found a high prevalence of prescribing and use of antibiotics in hospitalized patients across the surveyed hospitals in Zambia. The high use of Watch group antibiotics was above the recommended threshold indicating non-adherence to the WHO AWaRe guidelines for antibiotic use. Hence, there is a need to establish and strengthen antimicrobial stewardship programmes that promote the rational use of antibiotics in hospitals in Zambia.

Background: Antimicrobial stewardship (AMS) programs optimize the use of antimicrobials and reduce antimicrobial resistance (AMR). This study evaluated the implementation of AMS programs in Africa using a harmonized regional approach. Methods: This was an exploratory cross-sectional study across five countries involving 32 hospitals using an adapted Periodic National and Hospitals Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Results: This study found baseline scores for AMS core elements ranging from 34% to 79% at the baseline which improved to 58% to 92% at the endline. At baseline, Drugs and Therapeutics Committee (DTC) functionality in updating facility-specific medicines and medical devices ranged from 58% to 100%, and this ranged from 79 to 100% at endline. Classifying antibiotics by WHO AWaRe, classification ranged from 33% to 83% at baseline and 64% to 100% at endline. Leadership commitment scores were 47% at baseline and 66% at endline. Education and training scores were 42% and 63% at baseline and endline, respectively. Reporting and feedback scores were 34% at baseline and 58% at endline. Conclusions: Our study showed that understanding context and standardizing regional stewardship approaches enhanced cross-country learning and improved AMS implementation. Although the challenges in Low- and Middle-Income Countries (LMICs) are similar, they vary by country and can be addressed by strengthening AMS regulatory frameworks and surveillance systems.

Background: Kenya has moved from fragmented, pilot-based antimicrobial resistance (AMR) surveillance toward a coordinated One Health system, and its experience, pathways of change, and remaining gaps are relevant for other low- and middle-income settings working to operationalize One Health AMR surveillance. Methods: Here, we report a narrative overview of programmatic learning using 2018 as the pre-Fleming Fund baseline, drawing on national and global surveillance reports, monitoring frameworks from the Quadripartite indicators, qualitative evidence on governance, implementation and policy evolution across the One Health sectors, and Fleming Fund documentation. Results: Since 2018, AMR surveillance expanded from 2 human health sites to 30 human, animal, and environmental sites by 2025. National reports evolved to integrate AMR, antimicrobial consumption, and antimicrobial use data; routine reporting to global platforms matured; and outputs such as dashboards, reports, and policy briefs informing stewardship, Infection Prevention and Control, regulatory action, and policy decisions. External benchmarks showed improvement in AMR-related capacity, with World Health Organization Joint External Evaluation scores moving from limited to demonstrated capacity for surveillance and multisectoral coordination. Conclusions: Kenya's experience suggests that sustainable progress depends on embedding AMR surveillance within government-led governance structures, technical systems, and coordinated partner support, but sustaining gains will require predictable financing and routine data use.

Background: Drawing on the Fleming Fund's work to strengthen antimicrobial resistance (AMR) surveillance across Africa and Asia during 2018–2026, this article provides one of the first syntheses of AMR surveillance data use in low- and middle-income countries. Methods: A participatory synthesis for narrative review was conducted to summarize experience across administrative levels (facility, subnational, national, and regional). Results: Data use was most evident at the facility level, in human health systems where resistance patterns, antimicrobial use, and clinical data increasingly informed antimicrobial stewardship, infection prevention and control, and other quality improvement initiatives. Data use in other sectors required different approaches. At the national level, Fleming Fund investments were associated with revisions of treatment guidelines, updates of essential medicines lists, and regulatory measures, primarily through improved governance and policy communities. Regional platforms supported member country data use at the national level. Subnational data use was undertaken in countries with decentralized health systems. Across levels, data use pathways driven by local priorities helped surveillance inform action. Conclusions: Fleming Fund experience suggests that surveillance is more likely to inform action when data use is built into system design. Continued investment will be needed if AMR surveillance is to improve policy and practice in low- and middle-income countries.