Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

Figures & data

Box 1. Five Strategic Pillars within the WHO Global Action Plans to reduce AMR (adapted from [72,93,161,164])

Improve awareness and understanding of AMR among all key stakeholder groups Strengthen knowledge of AMR through improved surveillance and future research activities Seek to reduce the incidence of infections Introduce pertinent programs to optimize the future use of antimicrobials Develop an economic case for sustainable investment for new medicines, including new antibiotics, new vaccines, diagnostic tools, and other pertinent interventions to help counter growing AMR rates. In addition, promote research on AMR

Figure 1. Building blocks to help tackle AMR in Nigeria.

Figure 2. Implementation of the NAP and follow-up in Kenya.

Table 1. Current population size and GDP/capita among participating African countries.

Country	Population size	GDP/capita (US$)
Eswatini	1,160,164	3,415.5
Botswana	2,351,627	6,711.0
Namibia	2,540,905	4,211.1
Zimbabwe	14,862,924	1,128.2
Zambia	18,383,955	1,050.9
Malawi	19,129,952	625.3
Cameroon	26,545,863	1,499.4
Ghana	31,072,940	2,328.5
Uganda	45,741,007	817.0
Kenya	53,771,296	1,838.2
South Africa	59,308,690	5,090.7
Tanzania	59,734,218	1,076.5
Nigeria	206,139,589	2,097.1

Table 2. Key activities, groups, and evaluation of progress within NAPs to reduce AMR among sub-Saharan African countries.

Country	Summary of key activities
Botswana [58,69,74,114,189,190]	Botswana has committed to establishing a NAP (2018 – 2022) embracing the One Health approach. This was finalised in 2017; however, not currently launched as of early 2022 The National AMR Governance Structure (NARGS) Group will be responsible for implementing the NAP with Technical Working Groups appointed to ensure programme planning and implementation NARGS will be supported by key members from sectors including human, animal, agricultural and environmental health sectors as well as key academics, developmental partners and regulatory bodies/ councils Activities to create public awareness of AMR include developing and distributing relevant information as well as road shows/ radio talks and adverts on TV and the radio Alongside this, ad hoc training courses on AMR with IPC committees established within hospitals as well as increased monitoring of antimicrobial prescribing in hospitals against agreed guidance including reducing the extent of continued antibiotic prophylaxis post operatively to prevent surgical site infections (SSIs) Bi-annual reviews of key indicators as well as annual reviews of prioritized activities to help meet agreed goals. Key indicators include: Current antimicrobial utilisation patterns and assessed against current regulations % of healthcare facilities with IPC programmes in place as well as basic sanitation/ hygiene External quality assurance for laboratories participating in GLASS Functioning DTCs/ AMS groups within facilities especially public hospitals Continual lobbying of the Government and donors to secure necessary resources to achieve agreed goals Future quality indicators will involve monitoring utilisation based on the WHO AWaRe classification
Cameroon [191-194]	Currently only a limited number of hospitals in Cameroon have AMS groups, AMR surveillance structures, or IPC committees with currently no national IPC programme in place In addition, currently limited diagnostic capacity in Cameroon leading to high empiric use of antibiotics with no action plan currently for routine surveillance. This is not facilitated by limited funds currently being allocated to healthcare to improve the situation The NAP for AMR addressing the 5 key strategic elements (Box 1) was launched in 2018 to 2020, with AMR evolving from the sulphonamides in Cameroon the 1930`s to daptomycin in the 1950s and continuing. Some priority actions were identified in the NAP including the creation of awareness on the effect of AMR on health through mass communication programmes and education of stakeholders involved in the fight against AMR, establishing a surveillance system for AMR, and improving the laboratories/ capacity building to effectively detect resistant germs and reduce the incidence of infections by applying effective measures including AMS programmes to prevent resistant infections However, there are concerns with the implementation of key activities in the NAP including currently limited training regarding AMR across the country, especially given current high resistance rates to antimicrobials of clinical relevance in Cameroon. This needs to be addressed going forward
Eswatini [195,196]	The final draft of the NAP was made available at the end of 2017, with the Government of the Kingdom of Eswatini highly committed to curbing the spread of AMR in the Kingdom. The strategic objectives are in line with the WHO objectives (Box 1). With support from the Fleming Fund, the implementation plan of the NAP has been instigated with the following objectives: Translate the strategic objectives of the NAP into activities and actions. Align the implementation plan with existing policies, regulations, and guidelines, and identify opportunities for improvement. Facilitate national coordination of the implementation of AMR surveillance strategies in the different sectors. Monitor the implementation plan outputs and collating experiences for future adjustments. A multi-sectoral collaboration of different ministries within the country is now underway to promote a One Health approach to address concerns with current AMR rates in Eswatini. Key activities include: Strengthening of the governance and leadership of the AMR containment committee (AMRCC) to oversee and monitor AMR, antimicrobial use (AMU), and antimicrobial consumption (AMC) across sectors. Improving capacity for AMR and AMU/AMC surveillance across sectors; the human and animal health sectors and the environment The development of materials to help standardize operating procedures and protocols, enhance laboratory bench aids and improve national data flow systems in compliance with the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS). Instigation of monitoring and evaluation (M & E) activities including a plan to measure the progress of the strategic objectives. The coordination of the M& E will be carried out by the antimicrobial resistance containment committee (AMRCC) under the leadership of the One Health Committee (OHC) which is composed of senior officials from the three key ministries. Some data on antimicrobial utilisation (AMU and AMC) patterns and AMR is currently available in Eswatini. This will grow as more studies are undertaken, including PPS studies
Ghana [35,63,64,70,80,175,197-211]	The Ghana NAP (2017 – 2022) was launched in 2017 incorporating multiple stakeholders building on comprehensive AMR Platform Membership from 2011 onwards, with published studies showing the considerable economic impact of inappropriate antibiotic prescribing alongside general studies showing the impact on morbidity and mortality The key objectives were in line with strategic objectives of the WHO NAP (Box 1), with national IPC programmes and other programmes in place. In addition, creating an enabling environment for sustainable investment in Ghana to help fund new diagnostic tools, vaccines and new medicines to meet the growing unmet need Active monitoring of agreed strategic activities as part of the NAP including AMR monitoring using specific indicators that have been developed under each strategic objective and sub-objective of the NAP - specifying the data sources that inform each indicator or where data for the indicator can be obtained and targets for the stated indicator. In time, greater use of the AWaRe classification for antibiotics to enhance the future quality of antimicrobial prescribing given current concerns across sectors and populations. This is helped by a strong political will to reduce AMR in Ghana enhanced by increasing co-operation among key stakeholders There have also been studies assessing the impact of delayed prescribing of antibiotics for patients with upper RTIs in ambulatory care, with such activities likely to grow as this reduces over-prescribing of antibiotics However, there are concerns with available resources to fully implement the documented strategies although Ghana has been successful in obtaining donor support and working with groups in different countries to improve the use of antimicrobials across sectors through educational and other initiatives. There is still room for improvement as seen by concerns with adherence to guidelines for the management of community acquired pneumonia as well as the management of febrile outpatient in recent studies in Ghana Overall, Ghana has made appreciable progress towards including AMR as a key area within existing programmes and divisions. This includes nationwide, government-supported AMR awareness campaigns targeting the majority of priority stakeholder groups in Ghana, with prescribing practices increasingly monitored in hospitals and the community. However, there are concerns that no standardized national AST guidelines are currently in place, and with available resources for hospitals to purchase the necessary diagnostic equipment to regularly conduct diagnostic testing and produce up-to-date antibiograms for hospitals to guide empiric prescribing. There are also concerns regarding the extent of IPC activities within hospitals in Ghana These activities have been aided by Ghana hosting the second Global Call to Action on AMR, ongoing surveys to monitor outpatient prescribing against treatments recommended in the National Medicines Policy Guidelines as well as the development of electronic applications (Apps) as learning resources to improve future antibiotic prescribing
Kenya [103,104,164,212-231]	The Ministry of Health and Ministry of Agriculture, Livestock, Fisheries and Cooperatives, and other key stakeholders, launched the Kenyan NAP in 2017 with strategic objectives in line with the WHO NAP (Box 1) with implementation over a number of years including dissemination of AMR data (Figure 2) Regular education and awareness activities with annual AMR awareness events held over the last seven years to address AMR concerns. These efforts are guided by the National Communication Strategy on AMR and are accompanied by Information Education and Communication materials including a National One Health Training Curriculum. This consistency resulted in Kenya hosting the first Regional World Antibiotic Awareness Week in 2019 These activities build on growing concerns with rising AMR, rates across Kenya. They include establishing sentinel AMR surveillance sites as per the National AMR Surveillance Strategy as well as encouraging studies to improve key stakeholder knowledge of current antimicrobial utilisation and resistance patterns across sectors through a National AMR Surveillance Network as well as studies on AMS activities The National AMR Database, which is a One Health platform, is hosted within the Ministry of Health in Kenya. This helps ensure laboratories across Kenya use the same AST guidelines enforced through a standard one health training course on antimicrobial resistance. The surveillance sites are actively contributing AMR data to the National AMR surveillance system by implementing Surveillance Strategies developed for Human and Animal Health. To support Infection Prevention and Control, Water, Sanitation and Health, there exists a functional National IPC Programme with a guiding Policy and Strategy for IPC. Ongoing activities include strengthening national and regional IPC leadership and governance structures to support the implementation of the National IPC Policy and Strategy - adopting a continuous quality improvement approach to implementation for sustainability. For animal health the inclusion of hygiene and IPC as a core component of training and education for veterinary professionals is ongoing. In optimising the use of antimicrobial agents, Kenya has developed strategies to optimize and regulate the use of antimicrobials through the development and implementation of Guidelines for the Prudent Use of Antimicrobials in Animals, National AMS guidelines for Healthcare Settings, a National Integrated AMS Plan and more recently the Clinician’s Handbook on Diagnostic Stewardship to bridge the gap between the laboratory and the clinical teams. In addition to instigating national AMS guidelines, efforts have been augmented by the development of the first pre-service curriculum on antimicrobial stewardship. The NAP implementation process was further strengthened in 2021 through the development of a more comprehensive monitoring and evaluation framework to track progress over time. Overall, the national coordinating mechanisms and supporting technical working groups are seen as functional with clear terms of references and regular meetings to enhance successful implementation of agreed activities to reduce AMR
Malawi [32,232-235]	The Malawi NAP is a critical component of the Health Sector Strategic Plan II (HSSPII) running from 2017 to 2022, building on HSSPI, which ran from 2011 to 2016. The NAP provides a detailed operational plan building on the WHO strategic objectives (Box 1) and involves all key Ministries within Malawi, with ongoing investment from the Fleming Fund to help improve surveillance in the country to improve future antimicrobial use The key oversight functions of agreed AMR activities are being managed by the Ministry of Health through the AMR National Coordinating Centre, with the NAP now being implemented. There is also ongoing ad hoc training regarding AMR among key groups The Ministry of Health through the AMR National Coordinating Centre has also established the agenda for AMR surveillance among hospitalised patients and those in ambulatory care in Malawi in collaboration with key stakeholder groups given ongoing concerns. However, major modifications in the AST and bacterial isolation protocols used are required to improve their adaptation to meet national AMR surveillance objectives There are concerns though with the routine availability of essential antibiotics especially in rural settings, which may undermine attempts generally to improve antimicrobial utilisation in ambulatory care in Malawi Alongside this, there are also concerns with high use of broad-spectrum antibiotics within hospitals in Malawi with infrequent use of blood culture testing to improve prescribing. This is because whilst there are trained lab personnel in Malawi, very few facilities are able to undertake blood cultures, bacterial isolation and AST. The majority of district hospitals have to rely on full blood counts to support their diagnosis and prescribing leading to high broad spectrum antibiotic prescribing
Namibia [11,82,122,123,131,172, 236-238]	There have been ongoing activities across Namibia to improve antimicrobial use including activities by USAID funded projects (SIAPs). This includes a pharmaceutical management information system for monitoring of antimicrobial prescribing across sectors against agreed guidance to improve future antimicrobial use, with good adherence rates to guidelines in Namibia enhanced by easy access to up-to date objective guidelines with ease of referencing as well as support systems for continued education regarding their use Alongside this, monitoring antibiotic sensitivity patterns in hospitals The NAP for AMR has also been developed to guide prescribing and surveillance activities in Namibia; however, still awaiting government approval. The NAP includes educational and other activities; however, the routine collection of AMR data could be improved with currently no standardised national AST guidelines Encouragingly, the national standard treatment guidelines have been revised in 2021 to ensure that antibiotic choices are aligned to current resistance patterns and accessibility. There is also a dedicated unit within the directorate of pharmaceutical services to coordinate activities surrounding AMR and rational use of medicines Alongside this, the interest group NABIAN Against Antimicrobial Resistance (NAAR) have recently developed a guideline for antibiotic use, among other activities. In addition, existing policies restrict or control of antibiotic use in food animals The was considerable pro-activity among community pharmacists at the start of the recent COVID-19 pandemic to guide appropriate prevention and treatment, with community pharmacists in Namibia aware of the current regulations not to dispense antimicrobials without a prescription. This is continuing
Nigeria [62,84-86,147,239-251]	The production of the Nigerian NAP was led by the Nigeria Centre for Disease Control (NCDC) in collaboration with key Federal Agencies, Development partners, Academia, Healthcare institutions, and the private sector, and was launched in November 2017 The AMR structure implementing and monitoring activities comprises the Antimicrobial Resistance Coordinating Committee (AMRCC), the National AMR -Technical Working Group (NAMR-TWG) including stakeholders from all the key areas and divided into 5 pillars addressing key strategic implementation areas in line with the Global NAP (Box 1) The AMR governance structure adopted the One Health approach reporting to the National One Health Steering Committee (NOHSC) through the National One Health Technical Committee (NOHTC) involving the Director General of NCDC as well as the Chief Veterinary Officer of Nigeria. This is essential given concerns with current resistance rates in Nigeria across sectors as well as health care-associated infections (HCAIs), with mobilisation of resources ongoing to help achieve agreed objectives and goals There are continuing issues regarding the knowledge of healthcare workers in Nigeria regarding AMR, ASPs and information regarding antibiotics provided by independent sources; however, this is likely to change with ongoing implementation of the NAP. In addition, pertinent quality improvement programmes to enhance appropriate antibiotic prescribing across sectors as knowledge levels grow through point prevalence and other studies Progress of the NAP is being regularly monitored via Independent Joint External Evaluation of International Health Regulation (IHR) Core Capacities as well as quarterly meetings of the National AMR- Technical Working Group/ AMRCC Key achievements to date include (but not limited to): Establishment of National Reference Laboratories for AMR in human and animal health along with 35 human health (11 optimized presently) and 6 animal health sentinel laboratories across the country with support of groups including the Fleming Fund Country Grant along with laboratory capacity building programmes, with additional surveillance sites being added Routine AMR surveillance data collection across the country and reporting to the Global Antimicrobial Resistance Surveillance System (GLASS) through the NCDC. This should help standardise approaches across the country IPC guidelines developed along with the ‘Turn Nigerian Orange (TNO) initiative’ to help health facilities become IPC centres of excellence. Establishment/ strengthening of ASP activities in 10 tertiary hospitals selected as AMR surveillance sites to develop AMS action Plans and conduct PPS studies with support from the Fleming Fund Country Grant. This including launching AMS committees in four of these sites Commencement of a National Community of Practice on AMR and antimicrobial use to enhance awareness of AMR among healthcare professionals
South Africa [59,61,65,66,81,94,117, 124,178,190,252-270]	Integrated approaches have been used to progress the NAP in South Africa following its launch in 2017, and now in its second edition, with a co-ordinated One Health approach helping to improve antimicrobial utilisation and reduce resistance, e.g., concerns with rising resistance to colistin resulted in co-ordinated activities to reduce its use in animals as well as improve appropriate use among patients The NAP is being actively monitored through a standard monitoring and evaluation framework, which will continue Alongside this, active measuring of compliance against South Africa’s AMR strategy among healthcare facilities across South Africa including hospitals In addition, increased surveillance of AMR patterns across South Africa co-ordinated by the Ministry of Health as a key monitoring target within the NAP along with co-ordinated activities to improve IPC activities within healthcare facilities. This includes the development and dissemination of IPC guidelines, including their practical implementation, to raise awareness of AMR among all key stakeholder groups and ways to address key concerns. However, there are currently no standardised national antimicrobial sensitivity testing (AST) guidelines in place to improve surveillance, which need to be addressed There are an increasing number of studies being undertaken across sectors in South Africa to monitor current antimicrobial prescribing against agreed guidance given identified concerns, with the findings used to develop pertinent quality improvement programmes. This increasingly includes the use of specially developed Apps as well as the instigation of ASPs across hospitals to address identified concerns Alongside this, a number of pilot ASPs have been initiated in primary health care centres in the public sector to improve future antimicrobial use alongside investigating potential point-of-care testing in primary care for common infections. In addition, whilst AMS curriculum changes have been implemented at all pharmacy schools in South Africa, a subcommittee of the Ministerial Advisory Committee (MAC) for AMR is currently spearheading undergraduate changes at medical schools to enhance knowledge among undergraduates given current concerns. This is important with healthcare professionals in a recent study indicating the need for further training regarding antibiotics, AMR and AMS programmes to improve future prescribing, as well as concerns with the implementation of ASPs in line with the national AMR strategy Whilst the Department of Health and others have launched the Antibiotic Guardian campaign, there are ongoing concerns with public awareness of AMR in South Africa as rates continue to rise. In their recent study, Mokoena et al (2021) documented several misconceptions regarding antibiotics and their role among the minibus-taxi community. The study also highlighted the urgent need to standardise a common reference for antibiotics and resistance across linguistic barriers nationally. Identified enablers for public awareness and empowerment going forward included targeted public awareness campaigns There are also potential concerns regarding the dispensing of antimicrobials without a prescription, which need urgent exploration in future studies
Tanzania [63,83,271-274]	The NAP for Tanzania (2017 – 2022) involving all key Government Departments and incorporating the 5 Strategic Objectives of the Global NAP (Box 1) was launched in 2017 There are concerns with high and empiric use of antimicrobials among hospitals although encouragingly most prescribing has been from the Access Group and generally with high adherence to the Tanzania STGs although not universal In addition, concerns with extended prophylaxis to prevent SSIs among some hospitals in Tanzania leading to calls to enhance ASPs within the country. This is important with a recent study suggesting that hospital antibiotic policies were only present in 15.4% of health facilities surveyed, with only 17.9% regularly conducting prescribing audits and a similar number microorganisms susceptibility testing Greater educational activities can enhance knowledge of the NAP among health facilities with only 66.7% of personnel among surveyed facilities aware of the NAP This is already starting with the development of electronic Apps as learning resources to improve future antibiotic prescribing
Uganda [63,275-286]	The NAP for Uganda (2018 – 2023), which involved all key Government Departments and incorporated the 5 Strategic Objectives of the Global NAP (Box 1), was developed with assistance from the Ugandan National Academy of Sciences and CDDEP’s Global Antibiotic Resistance Partnership (GARP). The Fleming Fund was also involved in the development and dissemination of the NAP This is in response to high levels of resistance to commonly prescribed antimicrobials in Uganda. This is enhanced by over prescribing and dispensing of antibiotics across sectors including dispensing without a prescription, lack of diagnostic tools and over use in farming, driving up the improper use of antimicrobials across sectors, with polypharmacy being a big driver of improper use and abuse of antimicrobials Multifunctional groups appear to be working in Uganda implementing the NAP with reporting/accountability arrangements defined, as well as developing and implementing functional AMR surveillance strategies. Alongside this, electronic Apps have been developed as learning resources to improve future antibiotic prescribing across Uganda, given current concerns with compliance to current guidelines. Such activities are likely to grow given current challenges, including issues of ownership However, there are concerns that whilst some AMR data is being collected, there is no standardized approach affecting interpretation. National coordination and/or quality management is also lacking with major modifications needed for AST, bacterial isolation and identification protocols to attain national AMR surveillance objectives
Zambia [63,87,287-292]	The NAP was launched in 2017 involving all key stakeholder groups, including line government ministries, and incorporating the strategic objectives outlined in the WHO National Plan (Box 1). More recently, the integrated AMR surveillance framework has been launched - building on active surveillance of AMR in both human and animal health Along with this, a multisectoral national Antimicrobial Resistance Coordinating Committee (AMRCC) oversees and regularly monitors activities to achieve desired objectives contained within the NAP for AMR given concerns with current antimicrobial usage patterns and practices ASPs are currently being piloted in 7 healthcare facilities along with pieces of training on AMR and ASPs within in-service continuing education and pre-service training programmes for healthcare professionals The AMRCC is also monitoring stewardship interventions and antimicrobial use via PPS studies A national IPC programme is in operation and national guidelines for IPC committees are available and are being actively disseminated, with increased co-ordination of AST facilities to better track resistance patterns and develop local antibiograms especially in hospitals An AMR surveillance network has now been established with 5 laboratories regularly submitting data to the WHO GLASS (from 1 in 2016) along with more capacity building for surveillance in human and animal health Additional achievements include: Mainstream media (both electronic and print) regularly covering AMR topics AMR and AMS topics now part of undergraduate training for healthcare professionals Electronic Apps have been developed as learning resources to improve future antibiotic prescribing Undertaking baseline PPS studies across Zambia (11 facilities) with 4 additional sites added with help from WHO and other collaborating partners. In addition, planning PPS studies in Level 2 hospitals Baseline data on IPC activities being collected in 11 facilities according to international methodologies
Zimbabwe [8,173,234,293-298]	The NAP for Zimbabwe was launched in 2017 and runs until 2022 involving all key stakeholder groups and incorporating the strategic objectives outlined in the WHO National Plan (Box 1) The NAP has been implemented with multi-sectorial groups working together with clear terms of reference and monitoring of activities to push forward agreed goals This is seen as essential given concerns with high resistance rates to common antibiotics in Zimbabwe. However, there are concerns with available resources to fully fund all listed activities in the NAP without additional support from donors and other organisations There is ongoing support from the Fleming Fund and others to improve antimicrobial surveillance and capacity in Zimbabwe and reduce AMR. This will be achieved through upscaling the laboratory sector and upgrading two reference laboratories in the human health and animal The human health National Microbiology Reference Laboratory AMR Unit has already been commissioned to conduct antimicrobial sensitivity testing. In addition, a national IPC programme and operational plan are available, with national guidelines for IPC activities within healthcare facilities available and disseminated The Government has recently secured a grant of US$1million Antimicrobial Resistance (AMR) MULTI-PARTNER TRUST FUND to promote the use of vaccines across sectors, strengthen the National IPC programme by supporting a pilot surveillance system of HAIs in selected health facilities and conduct studies to better understand key drivers of AMR in different stakeholder groups to develop specific behaviour change intervention targets There are also ongoing strategies to raise awareness and address concerns with the prescribing of antibiotics across sectors to reduce future AMR rates

NB: Includes summaries within the WHO, FAO, and OIE global tripartite database; AMR, antimicrobial resistance; AMS, antimicrobial stewardship; ASP, antimicrobial stewardship programme; AST, antimicrobial sensitivity testing; CST, culture sensitivity testing; GLASS, Global Antimicrobial Resistance and Use Surveillance System; HAI, healthcare-associated infections; IPC, infection, prevention, and control; NAP, national action plan; PPS, point prevalence survey.

Table 3. Summary of key challenges among sub-Saharan African countries when implementing their NAPs.

	Available personnel including dedicated secretariat	Concerns with focal points for monitoring activities/co-ordinating activities	Capacity (surveillance laboratories)	Available funding	Competing demands/ priorities including donors	Challenges with inter-sectoral synchrony	Expertise/ knowledge/ activities regarding AMR/ AMS/ AMU
Botswana	√√	√√	√√	√√	√√	√√	√√
Cameroon	√√	√√	√√	√√	√√	√√	√√
Eswatini	LC	LC	LC	√	√	√	LC
Ghana	LC	LC	LC	√	√	LC	√
Kenya	LC	LC	√	√√	√	LC	LC
Malawi	√√	√√	√√	√√	√√	√√	√√
Namibia	√	LC	√	√	√	√	LC
Nigeria	LC	LC	√	√	√	√	√
South Africa	LC	√	LC	√ √	√	√	LC
Tanzania	√√	√√	√√	√√	√√	√√	√√
Uganda	√√	√√	√√	√√	√√	√√	√√
Zambia	LC	LC	√	√√	√√	LC	√
Zimbabwe	√	√	√	√	√	√	√

NB: √ = a challenge; √√ = a considerable challenge. LC, limited or no challenge.

Box 2. Summary of key activities to address current challenges

(A) Implementation – general  While African countries are all aware of the key issues necessary to reduce rising AMR rates, there is increasing recognition that the various sub-Saharan African countries do have different capability levels including variable technical and expert advice to enact the agreed NAPs  Increasing recognition that the different sub-Saharan African countries are willing to engage with donors and others to try and meet agreed NAP goals. This includes working with donors to secure future funding to improve AMR surveillance activities as well as assistance with implementing the findings from local/regional antibiograms to improve empiric prescribing  Improving articulation and communication of agreed activities among all key partners including greater transparency. This includes a deliberate coalition of people, partners, and the country to translate envisioned priorities into reality to inform real-world decisions to help focus resources, ensure accountability, and have impact  Enhancing engagement for end-to-end processes (from design to implementation) to improve joint ownership among key groups as well as enhance effective implementation and sustainability of agreed activities (B) Implementation – specific  Introduction/expansion of the education of all healthcare professionals including veterinary and plant health officers regarding antimicrobials/AMR/ASPs in undergraduate curricula with continuing education post qualification as well as using import and export data to improve knowledge of current antimicrobial consumption across all key sectors  Collecting baseline data on IPC to improve future activities within hospitals. Alongside this, increasingly undertaking PPS/additional PPS studies with key stakeholders to ascertain areas for future quality improvement programs across sectors. This includes monitoring prescribing against agreed guidance – increasingly adopting the WHO AWaRe classification for antimicrobials as part of performance indicators. Potential targets for AMS programs include reducing antimicrobial prescribing post surgery to reduce SSIs  Developing electronic Apps and other tools to shorten the time taken to undertake/ analyze PPS where pertinent as well as monitor the impact of pertinent quality improvement programs emanating from PPS studies  Orienting and equipping multidisciplinary healthcare teams regarding the introduction of ASPs in hospitals, secure funding for instigating ASPs as well as monitoring their implementation and outcomes. Similarly, initiating pilot studies regarding implementing ASPs in primary healthcare centers given current appreciable inappropriate prescribing of antimicrobials in ambulatory care exacerbated by the recent COVID-19 pandemic, with increased use of the WHO AWaRe classification as part of agreed quality indicators  Undertaking studies among community pharmacies to track the extent of inappropriate dispensing of antibiotics without a prescription and suggesting potential ways forward to reduce such activities building on positive experiences within African countries  Develop context-specific, validated scales, and survey tools to evaluate healthcare workers’ and the public’s attitudes, motivations, and expectations regarding antibiotic use and to use these tools in the long-term evaluation and monitoring of public health programs and interventions to reduce AMR  Instigate interventions to ensure adequate access to facilities and targeting healthcare workers and the public to ensure confidence in vaccines, high vaccination coverage, and combat vaccine hesitancy where concerns currently exist. Alongside this, improving supply chains to reduce the potential for shortages of key antimicrobials and vaccines as well as improve monitoring and other activities to help curtail the availability of sub-standard antimicrobials especially in ambulatory care  Introducing legislation and increasing surveillance regarding antimicrobial use in other key sectors including animal and plant sectors. As part of this, increasing the involvement of the agricultural and environmental sectors to achieve a One Health–based unified approach towards combating AMR  Improving knowledge of current antimicrobial use in animal, agriculture and plant sectors as well as resistance patterns

NB: AMR, antimicrobial resistance; AMS, antimicrobial stewardship; ASP, antimicrobial stewardship programme; AST, antimicrobial sensitivity testing; IPC, infection, prevention, and control; NAP, national action plan; PPS, point prevalence survey; SSI, surgical site infections; WHO, World Health Organization

Iwu CD, Patrick SM. An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: a roadmap for action. Int J Antimicrob Agents. 2021;58(4):106411.

 PubMed Web of Science ®Google Scholar

Elton L, Thomason MJ, Tembo J, et al. Antimicrobial resistance preparedness in sub-Saharan African countries. Antimicrob Resist Infect Control. 2020;9(1):145.

 PubMed Web of Science ®Google Scholar

WHO. Global action plan on antimicrobial resistance; 2015 [cited 2022 Jun 4]. Available from: https://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf?sequence=1

 Google Scholar

Republic of Kenya. National action plan on prevention and containment of antimicrobial resistance, 2017–2022; 2017 [cited 2022 Jun 4]. Available from: https://www.afro.who.int/publications/national-action-plan-prevention-and-containment-antimicrobial-resistance-2017-2022

 Google Scholar

Anand Paramadhas BD, Tiroyakgosi C, Mpinda-Joseph P, et al. Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications. Expert Rev Anti Infect Ther. 2019;17(7):535–546.

 PubMed Web of Science ®Google Scholar

Mpinda-Joseph P, Anand Paramadhas BD, Reyes G, et al. Healthcare-associated infections including neonatal bloodstream infections in a leading tertiary hospital in Botswana. Hosp Pract. 2019;47(4):203–210.

 PubMedGoogle Scholar

Mwita JC, Souda S, Magafu M, et al. Prophylactic antibiotics to prevent surgical site infections in Botswana: findings and implications. Hosp Pract. 2018;46(3):97–102.

 PubMedGoogle Scholar

Tiroyakgosi C, Matome M, Summers E, et al. Ongoing initiatives to improve the use of antibiotics in Botswana: university of Botswana symposium meeting report. Expert Rev Anti Infect Ther. 2018;16(5):381–384.

 PubMedGoogle Scholar

Mudzikati L, Dramowski A. Neonatal septicaemia: prevalence and antimicrobial susceptibility patterns of common pathogens at Princess Marina Hospital, Botswana. S Afr J Infect Dis. 2015;30(3):108–113.

 Web of Science ®Google Scholar

Gezmu AM, Bulabula ANH, Dramowski A, et al. Laboratory-confirmed bloodstream infections in two large neonatal units in sub-Saharan Africa. Int J Infect Dis. 2021;103:201–207.

 PubMed Web of Science ®Google Scholar

USAID, SIAPS. Development of Swaziland’s national antimicrobial resistance containment strategic plan. 2018 [cited 2022 Jun 4]. Available from: https://siapsprogram.org/wp-content/uploads/2018/03/18-032-AMR-Technical-Report_Jan2018.-V.4.final_.pdf

 Google Scholar

Zwane SP, McGee S-AM, Suleman F. A comparative cost analysis of antibiotic treatment for community acquired pneumonia (CAP) in adult inpatients at piggs peak government hospital in Swaziland. Front Public Health [Internet]. 2018;6. DOI:10.3389/fpubh.2018.00303.

 PubMed Web of Science ®Google Scholar

Godman B, Egwuenu A, Haque M, et al. Strategies to improve antimicrobial utilization with a special focus on developing countries. Life. 2021;11(6):528.

 PubMedGoogle Scholar

D’Arcy N, Ashiru-Oredope D, Olaoye O, et al. Antibiotic prescribing patterns in Ghana, Uganda, Zambia and Tanzania hospitals: results from the global point prevalence survey (G-PPS) on antimicrobial use and stewardship interventions implemented. Antibiotics. 2021;10(9):1122.

 Google Scholar

Afriyie DK, Sefah IA, Sneddon J, et al. Antimicrobial point prevalence surveys in two Ghanaian hospitals: opportunities for antimicrobial stewardship. JAC Antimicrob Resist. 2020;2(1):dlaa001.

 PubMedGoogle Scholar

Labi AK, Obeng-Nkrumah N, Owusu E, et al. Multi-centre point-prevalence survey of hospital-acquired infections in Ghana. J Hosp Infect. 2019;101(1):60–68.

 PubMed Web of Science ®Google Scholar

Sefah IA, Essah DO, Kurdi A, et al. Assessment of adherence to pneumonia guidelines and its determinants in an ambulatory care clinic in Ghana: findings and implications for the future. JAC Antimicrob Resist. 2021;3(2):dlab080.

 PubMedGoogle Scholar

Ogunleye OO, Basu D, Mueller D, et al. Response to the Novel Corona Virus (COVID-19) pandemic across Africa: successes, challenges, and implications for the future. Front Pharmacol. 2020;11:1205.

 PubMed Web of Science ®Google Scholar

Okoth C, Opanga S, Okalebo F, et al. Point prevalence survey of antibiotic use and resistance at a referral hospital in Kenya: findings and implications. Hosp Pract. 2018;46(3):128–136.

 PubMedGoogle Scholar

Sulis G, Daniels B, Kwan A, et al. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health. 2020;5(9):e003393.

 PubMed Web of Science ®Google Scholar

MacPherson EE, Reynolds J, Sanudi E, et al. Understanding antimicrobial resistance through the lens of antibiotic vulnerabilities in primary health care in rural Malawi. Glob Public Health. 2021:1–17. 10.1080/17441692.2021.2015615.

 PubMed Web of Science ®Google Scholar

Mabirizi D, Kibuule D, and Adorka M, et al. Promoting the rational medicine use of ARVs. Anti-TB, and Other Medicines and Preventing the Development of Antimicrobial Resistance in Namibia: Workshop and Stakeholders Forum; Namibia. 2013 [cited 2022 Jun 4]. Available from: https://pdf.usaid.gov/pdf_docs/PA00JP4B.pdf

 Google Scholar

Niaz Q, Godman B, Campbell S, et al. Compliance to prescribing guidelines among public health care facilities in Namibia; findings and implications. Int J Clin Pharm. 2020;42(4):1227–1236.

 PubMed Web of Science ®Google Scholar

Kamati M, Godman B, Kibuule D. Prevalence of self-medication for acute respiratory infections in young children in Namibia: findings and implications. J Res Pharm Pract. 2019;8(4):220–224.

 PubMed Web of Science ®Google Scholar

Kibuule D, Nambahu L, Sefah IA, et al. Activities in Namibia to limit the prevalence and mortality from COVID-19 including community pharmacy activities and the implications. Sch Acad J Pharm. 2021;10(5):82–92.

 Google Scholar

Kaupitwa CJ, Nowaseb S, Godman B, Kibuule D. Analysis of policies for use of medically important antibiotics in animals in Namibia: implications for antimicrobial stewardship. Expert Review of Anti-infective Therapy. 2022 (EPrint).

 Google Scholar

Harant A. Assessing transparency and accountability of national action plans on antimicrobial resistance in 15 African countries. Antimicrob Resist Infect Control. 2022;11(1):15.

 PubMed Web of Science ®Google Scholar

Ogunleye OO, Oyawole MR, Odunuga PT, et al. A multicentre point prevalence study of antibiotics utilization in hospitalized patients in an urban secondary and a tertiary healthcare facilities in Nigeria: findings and implications. Expert Rev Anti Infect Ther. 2022;20(2):297–306.

 PubMed Web of Science ®Google Scholar

Federal Ministries of Agriculture, Rural Development, Environment and Health, Abuja, Nigeria. National action plan for antimicrobial resistance, 2017–2022; 2017 [cited 2022 Jun 4]. Available from: https://ncdc.gov.ng/themes/common/docs/protocols/77_1511368219.pdf

 Google Scholar

Kruger D, Dlamini NN, Meyer JC, et al. Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa. Hosp Pract. 2021;49(3):184–193.

 PubMedGoogle Scholar

Skosana PP, Schellack N, Godman B, et al. A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications. Expert Rev Anti Infect Ther. 2021;19(10):1353–1366.

 PubMed Web of Science ®Google Scholar

Brink AJ, Messina AP, Feldman C, et al. Antimicrobial stewardship across 47 South African hospitals: an implementation study. Lancet Infect Dis. 2016;16(9):1017–1025.

 PubMed Web of Science ®Google Scholar

Department of Health Republic of South Africa. National infection prevention and control strategic framework. 2020 [cited 2022 Jun 5]. Available from: https://www.nicd.ac.za/wp-content/uploads/2020/04/National-Infection-Prevention-and-Control-Strategic-Framework-March-2020-1.pdf

 Google Scholar

van der Sandt N, Schellack N, Mabope LA, et al. Surgical antimicrobial prophylaxis among pediatric patients in South Africa comparing two healthcare settings. Pediatr Infect Dis J. 2019;38(2):122–126.

 PubMed Web of Science ®Google Scholar

Engler D, Meyer JC, Schellack N, et al. Compliance with South Africa’s antimicrobial resistance national strategy framework: are we there yet? J Chemother. 2021;33(1):21–31.

 PubMed Web of Science ®Google Scholar

Ncube NB, Solanki GC, Kredo T, et al. Antibiotic prescription patterns of South African general medical practitioners for treatment of acute bronchitis. S Afr Med J. 2017;107(2):119–122.

 PubMed Web of Science ®Google Scholar

Mokwele RN, Schellack N, Bronkhorst E, et al. Using mystery shoppers to determine practices pertaining to antibiotic dispensing without a prescription among community pharmacies in South Africa—a pilot survey. JAC-Antimicrob Resist. 2022;4(1). DOI:10.1093/jacamr/dlab196

 PubMedGoogle Scholar

Hanin MCE, Queenan K, Savic S, et al. A One Health evaluation of the Southern African Centre for Infectious Disease Surveillance. Front Vet Sci. 2018;5. DOI:10.3389/fvets.2018.00033

 PubMed Web of Science ®Google Scholar

Seni J, Mapunjo SG, Wittenauer R, et al. Antimicrobial use across six referral hospitals in Tanzania: a point prevalence survey. BMJ Open. 2020;10(12):e042819.

 PubMed Web of Science ®Google Scholar

Kalungia AC, Mwambula H, Munkombwe D, et al. Antimicrobial stewardship knowledge and perception among physicians and pharmacists at leading tertiary teaching hospitals in Zambia: implications for future policy and practice. J Chemother. 2019;31(7–8):378–387.

 PubMed Web of Science ®Google Scholar

Mpundu M Moving from paper to action – the status of national AMR action plans in African countries. 2020 [cited 2022 Jun 5]. Available from: https://revive.gardp.org/moving-from-paper-to-action-the-status-of-national-amr-action-plans-in-african-countries/

 Google Scholar

Government of Zimbabwe. The Zimbabwe one health antimicrobial resistance national action plan, 2017-2021; 2017. [cited 2022 Jun 4]. Available from: https://www.flemingfund.org/wp-content/uploads/23599b35adfb6d04c2d3f422d34bcff3.pdf

 Google Scholar

The Fleming Fund. Fleming Fund to tackle growing threat of drug resistance in Malawi and Zimbabwe; 2020 [cited 2022 Jun 5]. Available from: https://www.flemingfund.org/publications/fleming-fund-to-tackle-growing-threat-of-drug-resistance-in-malawi-and-zimbabwe/

 Google Scholar