Journal of Infectious Diseases & Preventive Medicine
Open Access

Antibiotic Stewardship Programs in Developing Nations: A Critical Evaluation

Jonathan Pierce^{* *}Correspondence: Jonathan Pierce, Centre for Infectious Disease Policy and Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, Email:

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Conclusion

Antibiotic stewardship programs are no longer optional they are essential tools in the global fight against antimicrobial resistance. In developing nations, the implementation of these programs is fraught with structural, cultural and economic challenges. However, dismissing stewardship as too complex or resource-intensive for low-income settings would be a critical mistake. Instead, what is needed is a pragmatic, context-sensitive approach that aligns with local realities. Simplified stewardship protocols, enhanced provider training, better diagnostic access and stronger regulatory frameworks must be pursued in tandem. Equally, high income countries must continue to support global stewardship through funding, capacity building and equitable access to technology and data. The future of antibiotic effectiveness depends on what actions are taken today not only in advanced healthcare systems but across the globe. The burden of resistance does not respect borders and neither should the responsibility for solving it.

Description

Antibiotic resistance represents one of the most serious public health threats of our time and Antibiotic Stewardship Programs (ASPs) have emerged as an essential strategy to combat it. While such programs have seen structured implementation and measurable success in many high-income countries, their adoption in developing nations remains inconsistent, underfunded and often poorly integrated into broader healthcare systems. ASPs are designed to promote the appropriate use of antimicrobials, improve patient outcomes, reduce microbial resistance and decrease the spread of infections caused by multidrug-resistant organisms. Core strategies typically include guideline development, surveillance of antibiotic use and resistance patterns, education of healthcare providers and institutional policy changes to reduce misuse.

In developing nations, however, several systemic challenges hinder the success of these programs. Foremost among them is the over-the-counter availability of antibiotics without prescription, a practice that remains widespread in many parts of Asia, Africa and Latin America. Limited regulatory enforcement enables self-medication and contributes heavily to the development of resistance. In the absence of strong legal frameworks, stewardship efforts struggle to gain meaningful traction. Another major obstacle is the lack of reliable diagnostics and laboratory capacity. Without timely and accurate identification of pathogens, healthcare providers in resource-limited settings often rely on empirical prescribing. This increases the likelihood of broad-spectrum antibiotic use, which further accelerates resistance. In many public hospitals across low- and middle-income countries, even basic bacterial cultures are not routinely performed, making it difficult to track resistance trends or guide treatment effectively.

There is also a severe shortage of trained personnel to design and implement stewardship protocols. Infectious disease specialists, microbiologists and pharmacists leads in successful ASPs are often few and overburdened in developing healthcare systems. Without cross-disciplinary collaboration and leadership, stewardship becomes fragmented or reduced to ad hoc interventions rather than a coordinated institutional strategy. Cultural and behavioural factors cannot be ignored either. In many developing nations, patients perceive antibiotics as a marker of "strong" treatment and may pressure healthcare providers to prescribe them, even for viral illnesses. Similarly, prescribers often operate under heavy workloads and with minimal support, leading to habitual or defensive prescribing. These deeply rooted behaviours pose significant barriers to rational antibiotic use.

Despite these challenges, there are potential initiatives that demonstrate how stewardship can be adapted and applied in resource-limited settings. For example, in India, the "Chennai Declaration" brought together medical societies, government stakeholders and hospitals to propose a road map for antibiotic policy and stewardship. In Tanzania and Ghana, pilot ASPs supported by international partnerships have shown early success in reducing inappropriate antibiotic prescriptions through clinician education and simple intervention tools such as audit and feedback. Digital technology also offers innovative potential. Mobile-based prescribing support, telemedicine consultations and real-time resistance tracking apps are increasingly feasible in regions where mobile phone penetration is high. These tools could help bridge some gaps in training and diagnostic access if scaled thoughtfully.

Furthermore, international organizations, including the World Health Organization (WHO), have recognized the urgency of this issue. WHO’s Global Action Plan on Antimicrobial Resistance encourages all member states, including those in the Global South, to develop national stewardship frameworks. However, translating these plans into functional, on-the-ground programs requires sustained political will, funding and local adaptation. Funding remains a central issue. Most stewardship programs in developing countries are donor-supported or externally initiated. There is a need for national governments to internalize stewardship as a priority health investment, not merely as an externally imposed requirement. Long-term sustainability depends on embedding ASPs into existing healthcare structures and aligning them with broader public health goals such as universal health coverage and health system strengthening.