Antimicrobial Stewardship in Low- and Middle-Income Countries (LMIC): Challenges & Opportunities

Abstract

Antibiotic resistance is an escalating global public health threat, with a particularly severe impact in low- and middle-income countries (LMICs). Rational use of antibiotics in both human and animal health—referred to as antibiotic stewardship—is a central pillar of the World Health Organization’s Global Action Plan on antimicrobial resistance. Many LMICs are currently in the process of developing and strengthening antibiotic stewardship programs. These initiatives aim to optimize antimicrobial use to improve patient outcomes, minimize adverse drug effects, enhance cost-effectiveness, and curb the emergence and spread of resistant organisms. Projections suggest that antimicrobial resistance could account for up to 10 million deaths annually by 2050, surpassing the present global mortality burden of cancer. A review of literature from PubMed, Google Scholar, relevant organizational websites, and expert consultations highlights both the challenges and opportunities associated with implementing antimicrobial stewardship in LMICs. Although evidence supporting effective and scalable stewardship interventions in these settings remains limited, several international and regional initiatives across Latin America, Africa, and Asia have demonstrated that successful stewardship is achievable when interventions are adapted to local contexts. However, implementation is often constrained by limited resources, weak healthcare infrastructure, and insufficient regulatory frameworks. To address these gaps, there is a clear need for LMIC-specific guidelines for establishing and sustaining antimicrobial stewardship programs. Priority actions should include improving access to diagnostic testing, strengthening education and training on antimicrobial resistance for healthcare professionals and the public, enhancing regulatory oversight of antimicrobial production, distribution, and dispensing, reinforcing healthcare systems, fostering collaboration among policymakers, academic institutions, professional organizations, and civil society, and developing simple, cost-effective, and scalable stewardship interventions suitable for both hospital and community settings.